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JULY 1962

NONPOLIOVIRUSES AND PARALYTIC DISEASE, Robert L. Magoffin, M.D., M.P.H., and

Edwin H. Lennette, M.D., Ph.D., Berkeley 1

HUMAN RENAL TRANSPLANTATION, II— A Successful Case of Homotransplanta-
tion of the Kidney Between Identical Twins, Willard E. Goodwin, M.D., Matt M.
Mims, M.D., Joseph J. Kaufman, M.D., Roderick D. Turner, M.D., Ralph Goldman,
M.D., William Bonney, M.D., Franklin Ashley, M.D., Richard Glassock, M.D., Los Angeles,

and Peter Bruce, F.R.C.S., Melbourne . . 8

CRITERIA FOR BLOOD TRANSFUSIONS. Noble A. Powell, Jr., M.D., and D. Gordon John-
ston, M.D., Oxnard 12

TRANSFUSIONS — Hazardous Acid-Base Changes with Citrated Blood, Jovita M. San
Pedro, M.D., Seizo Iwai, M.D., Mitsuo Hattori, M.D., and M. Digby Leigh, M.D., Los
Angeles 16

CARE OF THE UMBILICAL CORD IN THE NEWBORN— A Program to Reduce Infec-
tion and Promote Healing, John B. Sarracino, Lieutenant Colonel, M.C., Patricia A.

Ryan, Major, A.N.C., and Ellen Mastroianni, Major, A.N.C., U.S. Army Hospital, Fort
Ord 22

A ROLE FOR THE PHYSICIAN IN CIVIL DEFENSE. Max L. Lichter, M.D., Melvindale,

Michigan 24

MEDICAL MISCELLANY:

Help for Male Nocturics — A Flexible, Reversible Urinal, Wilson Stegeman, M.D.,

Santa Rosa 27

Mechanical Aids at the Operating Table, Richard C. Thompson, M.D., San Mateo,

and William B. Neff, M.D., Redwood City 28

CASE REPORTS:

Recurrent Tetanus, Harvey D. Cain, M.D., Vallejo, and Frank G. Falco, M.D., Pacific

Palisades 31

Arthrodesis of a Knee for Neuropathic Disease, Frank E. Winter, M.D., Visalia 33
Retroperitoneal Free Air, Lawrence Duckler, M.D., Portland, Oregon 35

CALIFORNIA MEDICAL ASSOCIATION:

Council Meeting Minutes, 481st Meeting, May 19, 1962 38

C.M.A. 1963 Annual Meeting — First Call for Scientific Presentations 43

INFORMATION: “

Hospital Bills — What Portion Is Paid by Insurance? — Report of Bureau of

Research and Planning 45

EDITORIAL, 36 • WOMAN'S AUXILIARY, 47 • NEWS AND NOTES, 48

BOOK REVIEWS, 49

ME 97

NUMBER 1

HEALTH trc

^fVER<im Z * LIBRAIty

Jl'.0F MARy^m

i^mmoRE

DIAGNOSIS:

Pyelonephritis

CLOMYCIN

Demethylchlortetracycline Lederle

oecause n is mgniy enctiive against the common patho-

gens in G*U. infections.

Request complete information on indications, dosage, precautions and contraindications from your Lederle representative, or write to Medical Advisory Department,

LEDERLE LABORATORIES, A Division of AMERICAN

CYANAMID COMPANY, Pearl River, New York

REFERENCES

AND REVIEWS

A Study of “Mentally Healthy” Young Males (Homo-
clites) — R. R. Grinker, Sr., R. R. Grinker, Jr., anti J.
Tiniberlake. Arch. Gen. Psychiat.— Vol. 6:405 (June)
1962.

A sample population of apparently mentally healthy
young adult males was studied by interview and question-
naire techniques, to ascertain their current behaviors and to
determine how and under what conditions they developed.
It was possible to separate the subjects into groups repre-
senting degrees of adjustment in order to determine signifi-
cant behavioral and genetic differences. The term “homo-
elite” was coined to mean nondeviant or “following the
common rule,” to avoid the values inherent in terms like
“normal” or “healthy.” The literature on mental health is
briefly reviewed. A theoretical discussion attempts to em-
phasize the hypothetical formulations derived from the study.
* * *

Repository Pollen Therapy — M. A. Green. Ann. Allergy
— Vol. 20:193 (March) 1962.

Major deterrents to the general use of repository de-
sensitization therapy have been the occurrence of severe
constitutional and local reactions. Significant reduction of
these undesirable side effects was effected by the use of
advanced, meticulous techniques of preparation and ad-
ministration of emulsified antigens, preceded by prophylactic
sustained-action oral antihistamines and methylprednisolone.
In 1935 repository injections given to 516 patients there was
virtual elimination of significant local reactions. No systemic

reactions followed 653 repositary pollen injections in pa-
tients given 3 oral doses of the medication, (1) the evening
before, (2) one hour before, and (3) the evening after
injection. In a total of 282 injections in which prophylactic
medication was omitted the night before, 4 immediate and
no delayed constitutional reactions developed.

* * *

Expiratory Carbon Dioxide Concentration Curve: Test
of Pulmonary Function — -J. E. Kelsey, E. C. Oldham,
and S. M. Horvath, Dis. Chest — Vol. 41:498 (May) 1962.

A test of pulmonary function based on the configuration
of the expiratory carbon dioxide concentration curve is de-
scribed. This curve is obtained by having the subject exhale
directly through a rapid response infrared gas analyzer
using a breathe-through cell and a strip chart recorder.
The test is effective in separating subjects with normal pul-
monary function from patients with pulmonary emphysema
of varying degree. The respiratory carbon dioxide concen-
tration curve is a valuable test of pulmonary function be-
cause of the ease with which it can be obtained.

* * *

Role of Pulmonary Resections for Tuberculosis in
Presence of Drug-Resistant Tubercle Bacilli — T.
Haga, T. Asano, S. Watanabe, R. Koga, M. Ono, K.
Yoshimura, and R. Yoneda. Dis. Chest — Vol. 41:504
(May) 1962.

From 1948 to 1959, 2,523 pulmonary resections for tuber-
culosis performed at a national sanatorium have been
studied in regard to complication by sputum status prior to
operation. In the contaminated group, there was no signifi-
cant difference in the proportion of complications regard-
less of sputum status. In the noncontaminated group
streptomycin cases showed a higher incidence of complica-
( Continued on Page 56)

ft.

VIRTUALLY NO CARBONIC [

ANHYDRASE INHIBITION

.ESS POTASSIUM LOSS

mmm

In addition to inhibition of sodium and chloride resorption, chloro-
thiazide and hydrochlorothiazide inhibit carbonic anhydrase. Carbonic
anhydrase inhibition is implicated in increased potassium loss.

Naturetin, on the other hand, is a single-action diuretic, acting solely
on tubular reabsorption ; it has virtually no carbonic anhydrase activ-
ity. This single action may explain the fact that Naturetin produces
less potassium loss than other benzothiadiazines and is therefore of
particular value in patients prone to hypokalemia or those on digitalis.

AVAILABLE: Naturetin 5 mg. and 2.5 mg. tablets. ALSO AVAILABLE: Naturetin c K (Squibb Ben-
droflumethiazide 5 mg. and 2.5 mg. capsule-shaped tablets, each with 500 mg. Potassium
Chloride), for use when disease or concomitant therapy increases the risk of hypokalemia.
For full information, see your Squibb Product Reference or Product Brief.

Naturetin —the diuretic with specific difference

SQUIBB BENDROFLUMETHI AZIDE

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JULY 1962

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this could be your “anxiety patient” on

In the treatment of mild to moderate ten
sion and anxiety, the normalizing effect of
TREPIDONE leaves the patient emotionally
stable, mentally alert. Adult dose: OneS
400 mg. tablet, four times daily. Supplied :
Half-scored tablets, 400 mg., bottle of 50.

MEPHENOXALONE LEDERLE

LEDERLE LABORATORIES, A Division of AMERICAN CYANAMID COMPANY, Pearl River, New York (ggBgji

Antibacterial Drugs Prevent
Travelers' Bane

A sulfa drug has proved effective in preventing
so-called “travelers’ diarrhea” in a signifiant number
of persons, four New York City researchers reported
recently.

In a study involving 473 college students newly
arrived in Mexico City, the drug, phthalylsulfathia-
zole, reduced the incidence of this common tourists’
bane by 50 per cent, the medical group reported
in the May 5 Journal of the American Medical
Association.

Another antibacterial drug, neomycin sulfate,
tested among college students in Mexico City, also
reduced the incidence of the disease, B. H. Kean,
M. D.. William Schaffner, B. S., Robert W. Brennan,
A.B., and Somerset R. Waters, B.E. said.

The combined effects of the drugs reduced the
incidence of the more incapacitating variety of the
syndrome by two-thirds, they said.

Both drugs suppress the growth of bacteria in the
large intestine, the researchers said.

The causes of travelers’ diarrhea is not known,
they said, but the effectiveness of these antimicro-
bial agents lends support to the suggestion that
bacteria may be involved.

Mexico was selected as the site for the investiga-
tion because of the prevalence of tourist diarrhea
among visiting students and because educational

and governmental officials cooperated completely,
they said.

Two studies were conducted, one in the summer
of 1960, the other in the winter of 1960-1961, they
said.

The students were given either a placebo (a
medicinally inactive pill) or one of the two active
drugs in pill form to be taken for two weeks.

Among 168 students taking the placebo, 23.8 per
cent suffered the illness, the researchers reported.
Of 137 taking neomycin, 16.1 per cent became ill
and of 168 taking phthalylsulfathiazole, 11.9 per
cent became ill. they said.

The effectiveness of the antibacterials in prevent-
ing moderate and severe forms of the syndrome also
was ascertained. Of 168 students receiving the
inactive pill, 17.3 per cent suffered more severe
symptoms, they said. Of the 137 receiving neomy-
cin, 5.1 per cent were more seriously affected and
of the 168 students receiving phthalylsulfathiazole,
6.6 per cent fell into the more severe category, they
said.

“This syndrome is so prevalent as to constitute
an important health problem to the large and grow-
ing tourist population,” the researchers commented.
“The threat of tourist diarrhea has led many tra-
velers to seek medical counsel or to resort to their
own devices in self-medication.”

Previous studies have shown that the most pop-
( Continued on Page 48)

MORE URINE

INCREASED WEIGHT LOSS

Naturetin has greater diuretic action1-3 than either chlorothiazide or
hydrochlorothiazide. A trial with Naturetin demonstrates the increased
urine volume and the greater weight loss it provides.

Moreover, the diuretic effect of Naturetin is controlled, sustained and
gradual, a sharp contrast to the distressingly abrupt initial diuresis
characteristic of shorter acting diuretics. Naturetin maintains a favor-
able urinary sodium-potassium excretion ratio.2

1. Ford, R. V.: Clin. Res. Notes 2:1 (Dec.) 1959. 2. Ford, R. V.: Cur. Therap. Res. 2:92 (Mar.) 1960.
3. Elliott. J. P., Jr., and Goldman, A. M.: South. M.J. 54:794 (July) 1961.

Naturetin —the diuretic with specific difference

SQUIBB BENDROFLUMETHr*’”'-

Squibb \ mi Squibb Quality — the Priceless Ingredient

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Min

Advertising • JULY 1962

AN AMES CLINIQUICK*

CLINICAL BRIEFS FOR MODERN PRACTICE

TEST

I OUTINE
FOR

PROTEIN

In a recent series of 278 diabetic patients, 34.2 per cent (95) had proteinuria.
Of this group, almost 3 out of 5 had previously unrecognized renal disease, usually
asymptomatic and untreated.1 Proteinuria may give valuable warning not only of
infectious and other renal disorders, but also of degenerative diabetic nephropathy.2

With Uristix Reagent Strips, testing for proteinuria and glucosuria may be conven-
iently done at the same time. Uristix is “. . . reliable for routine clinical use.”1 It will
not give false-positive protein reactions with oral hypoglycemic agent metabolites.
Uristix is simple for patients to use at home and is timesaving for technicians.1

References: (1) Moss, J. M.; Schreiner, G. E., and Sweeney, V.: M. Times 89: 12 (Jan.) 1961. (2) El Mahallawy, M.,
and Sabour, M. S.: J.A.M.A. 173: 1783 (Aug. 20) 1960.

for broader day-to-day protection of the diabetic patient

DIP

AND

READ

uristix

urine protein • gtucose

AMES

COMPANY, INC

Toronto • Canado

1 dip ... 10 seconds ... 2 readings

available: Uristix Reagent Strips, bottles of 125

20062

CALIFORNIA MEDICINE

Red Blood Cells Checked
In Heart Attacks

Researchers are investigating increased red blood
cell production as a possible contributing factor in
heart attacks.

Writing in the April 7 journal of the American
Medical Association, Drs. George E. Burch and
Nicholas P. DePasquale, New Orleans, said they had
found that 100 persons who suffered fatal heart
attacks had a “significantly higher” level of red
blood cells than 100 comparable persons with no
heart disease.

Although it is not possible to draw any definitive
conclusions from this study, the data suggest that
the incidence of heart attacks, particularly in young
patients, is influenced by red blood cell production,
the authors said.

It is not known to what extent red blood cell vol-
ume influences the function of the heart muscles
and flow of blood through the coronary arteries,
they said. However, they said, it is known that heart
attacks may occur when there is no obstruction in
the coronary arteries.

“This would suggest that the flow of blood has
stopped as a result of a functional, rather than an
organic or physical, obstruction,” they said.

Red blood cell volume affects the viscosity, or
gumminess, of blood to various degrees throughout
the body, the authors explained. Near a narrowed

segment of artery, the viscosity of blood would tend
to increase and the flow of blood to slow down, they
said. In this situation, red blood cell production
might tend to predispose to the formation of a clot
within the artery, they said.

The failure of coronary circulation which occurs
in a heart attack is probably related, in part, to the
inability of the heart to produce enough pressure to
force the blood through a markedly narrowed seg-
ment of coronary artery, they said. The viscosity
of the blood “must certainly play a role” in deter-
mining the pressure necessary to maintain blood
flow through a narrowed artery, they said.

These concepts are highly speculative, the authors
added, since the fluid properties of blood in the
coronary arteries have received little study.

However, they said, their findings indicate that
red blood cell volume should be reduced in patients
with coronary artery disease if the volume is above
a certain level.

The two physicians are affiliated with Tulane Uni-
versity School of Medicine.

Curable Arthritis: Treatment of Chronic Hypertrophic
Pulmonary Osteoarthropathy by Surgery of Chest —
E. F. Skinner. Dis. Chest — Vol. 41:571 (May) 1962.

A chest x-ray film is recommended as part of the routine
examination of any patient with arthritis. If chronic hyper-
trophic pulmonary osteoarthropathy is present, it is some-
times curable by eliminating the pulmonary disease with
appropriate therapy.

LESS BICARBONATE LOSS

LESS ALTERATION
IN URINARY pH

Unlike chlorothiazide or hydrochlorothiazide, Naturetin has virtually
no carbonic anhydrase activity. Thus, Naturetin causes less bicarbon-
ate loss and less alteration in urinary pH than these other agents. This
helps maintain a more favorable acid-base balance, and the less alka-
line urine reduces the risk of existing urinary infection becoming
resistant to therapy. Further, since Naturetin has less influence than
the other thiazides on normal uric acid excretion, it is considered the
thiazide of choice in patients with a tendency to hyperuricemia or
gout.1-2

AVAILABLE: Naturetin 5 mg. and 2.5 mg. tablets. ALSO AVAILABLE: Naturetin c" K (Squibb Ben-
droflumethiazide 5 mg. and 2.5 mg. capsule-shaped tablets, each with 500 mg. Potassium
Chloride), for use when disease or concomitant therapy increases the risk of hypokalemia.
For full information, see your Squibb Product Reference or Product Brief.

1. Cohen, B. M.: M. Times
(Mar. 15) 1961.

3 : 855 (July) 1960. 2. Cohen, B. M.: Med. et Hyp:. (Geneve) #494, p. 210

Naturetin —the diuretic with specific difference

SQUIBB BENDROFLUMETHIAZIDE

Squibb

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a DIVISION

Olin

Advertising •

JULY 1962

blood pressure approaches normal
more readily, more safely.... simply

Sllutensiri

(hydroflumethiazide, reserpine, protoveratrine A-antihypertensive formulation)

Early, efficient reduction of blood pressure. Only Salutensin combines
the advantages of protoveratrine A (“the most physiologic, hemody-
namic reversal of hypertension”1) with the basic benefits of thiazide-
rauwolfia therapy. The potentiating/additive effects of these agents2-8
provide increased antihypertensive control at dosage levels which
reduce the incidence and severity of unwanted effects.

Salutensin combines Saluron® (hydroflumethiazide), a more effective
‘dry weight’ diuretic which produces up to 60% greater excretion of
sodium than does chlorothiazide9; reserpine, to block excessive pressor
responses and relieve anxiety; and protoveratrine A, which relieves
arteriolar constriction and reduces peripheral resistance through its
action on the blood pressure reflex receptors in the carotid sinus.

Added advantages for long-term or difficult patients. Salutensin will re-
duce blood pressure (both systolic and diastolic) to normal or near-
normal levels, and maintain it there, in the great majority of cases.
Patients on thiazide/rauwolfia therapy often experience further improve-
ment when transferred to Salutensin. Further, therapy with Salutensin is
both economical and convenient.

Each Salutensin tablet contains: 50 mg. Saluron® (hydroflumethiazide), 0.125 mg. reserpine, and
0.2 mg. protoveratrine A. See Official Package Circular for complete information on dosage, side
effects and precautions.

Supplied: Bottles of 60 scored tablets.

References: 1. Fries, E. D.: In Hypertension, ed. by J. H. Moyer, Saunders, Phi la. , 1959 p. 123.
2. Fries, E. D.: South M. J. 51:1281 (Oct.) 1958. 3. Finnerty, F. A. and Buchholz, J. H.: GP 17:95
(Feb.) 1958. 4. Gill, R. J., et al.: Am. Pract. & Digest Treat. 11:1007 (Dec.) 1960. 5. Brest, A. N.
and Moyer, J. H.: J. South Carolina M. A. 56:171 (May) 1960. 6. Wilkins R. W.: Postgrad. Med.
26:59 (July) 1959. 7. Gifford, R. W., Jr.: Read at the Hahnemann Symp. on Hypertension, Phila.
Dec. 8 to 13, 1958. 8. Fries, E. D., et al.: J. A. M. A. 166:137 (Jan. 11) 1958. 9. Ford, R. V. and
Nickell, J.: Ant. Med. &. Clin. Ther. 6:461, 1959.

all the antihypertensive benefits of thiazide-
rauwolfia therapy plus the specific,
physiologic vasodilation of protoveratrine A

11 WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS BY SERIAL ADDITION OF
THE INGREDIENTS IN SALUTENSIN IN A TEST CASE

(Adapted from Spiotta, E. J.: Report to Department of Clinical Investigation, Bristol Laboratories)

SALUTENSIN

(thiazide

mm thiazide protoveratrine A

protoveratrine A reserpine)

3Vi WEEKS TO LOWER BLOOD PRESSURE TO DESIRED LEVELS USING SALUTENSIN FROM
THE START OF THERAPY IN A “DOUBLE BLIND” CROSSOVER STUDY

Mean Blood Pressures-Systolic (S) and Diastolic (D)

mm
Hg.

190
180
170
160
150
140
130
120
110
100
90
80
70
60
, 50

In this “double blind” crossover study of 45 patients, the mean systolic and diastolic blood pres-
sures were essentially unchanged or rose during placebo administration, and decreased markedly
during the 25 days of Salutensin therapy. (Smith, C. W.: Report to Department of Clinical Investi-
gation, Bristol Laboratories.)

BRISTOL LABORATORIES/Div.of Bristol-Myers Co., Syracuse, N.Y.

Placebo Followed by Salutensin
(22 patients)

Salutensin Followed by Placebo
(23 patients)

Placebo
Before After

Salutensin
Before After

Placebo
Before After

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New Lead in Search for Cause of MD

A new lead was reported recently in the search for
the cause or causes of muscular dystrophy.

An abnormality in the distribution of magnesium
in the blood of persons suffering the childhood type
of the disease was reported by Harris L. Smith,
M.D., Robert L. Fischer, Ph.D., and James N. Ettel-
dorf, M.D., Memphis, Tenn.

This previously unrecognized abnormality ap-
pears to involve the combining of magnesium with
some as yet unidentified substance, perhaps protein,
of high molecular weight, the researchers said in
the June American Journal of Diseases of Children,
published by the American Medical Association.

Because of the significant roles played by mag-
nesium and calcium individually and their apparent
interrelationships in muscle contraction and relaxa-
tion, 21 patients ranging from 3 to 29 years of age
were studied to determine the levels of these two
metal ions in the blood and in the residue after the
blood had been processed by ultrafiltration, they
said. The results were compared with 34 normal
persons, they said.

The calcium levels among the patients and the
normal group did not differ significantly, they said.

On the other hand, twice as much magnesium was
found in the blood of normal persons as in dys-
trophic patients, they said. However, the magnesium
(Continued on Page 38)

RALEIGH HILLS
HOSPITAL*

Member of the American Hospital Association
Recognized by the American Medical Association

EXCLUSIVELY for the TREATMENT of

ALCOHOL ADDICTION

by Conditioned Reflex and Adjuvant Methods

MEDICAL STAFF:

John R. Montague, M.D. Merle M. Kurtz, M.D.
Norris H. Perkins, M.D.

John W. Evans, M.D., Consulting Psychiatrist

ADMINISTRATORS:

Larrae A. Haydon Jean B. Tanner

RALEIGH HILLS HOSPITAL

6050 S.W. Old Schools Ferry Road
Portland 7, Oregon
Mailing Address: P. O. Box 366
Telephone: CYpress 2-2641

^FORMERLY RALEIGH HILLS SANITARIUM, INC.

CALIFORNIA MEDICINE

9 vears of control

When the patient underwent
surgery that same year, she was
given insulin, 30 units, 2 days
preoperatively and 8 days post-
operatively. After this 10-day
interval, she resumed her usual
level of 1 Gm. Orinase daily,
and has since then been
consistently well managed on
that dosage.

Mrs. G. has now been Orinase-
treated for 5'h years, living a
busy life, with her diabetes
controlled and without untoward
developments.

jring an extended trip in 1959,
e patient reacted adversely
a severe sunburn. On return-
3 home, Mrs. G. (shown
her husband helps her from
eir car), required increased
•inase (3 and then 2 Gm. daily)
r several months.

rinase* (tolbutamide) stands in a unique position; it alone,
nong oral antidiabetes agents, has had five years or more
day-to-day routine clinical use in the hands of thousands
physicians throughout the country. Accordingly, there are
r now a considerable number of truly long-term Orinase-
sated patients. A series of Orinase five-year case histories
is been prepared to illustrate and exemplify some as-
sets of actual experience in management. Patient data,

made available to us by the respective physicians, have

been factually incorporated; however, patients’ identities
have been concealed. Any inquiries regarding this Orinase
case history series should be addressed to: Medical

Department, The Upjohn Company, Kalamazoo, Michigan.

Orinase is supplied in bottles of 50 and 200 tablets.
Each tablet contains: Tolbutamide ... 0.5 Gm.
Reminder advertisement. Please see package insert
for detailed product information.

Upjohn

The Upjohn Company, Kalamazoo, Michigan

For Senior Patients

THE

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New Lead in Search for Cause of MD

(Continued from Page 34)

found after ultrafiltration was about the same in
both groups, they said.

From this finding, the authors theorized that
there is an abnormal binding of magnesium to some
other substance in the blood of persons with the
childhood type of MD. The process of ultrafiltration
removes or eliminates the substance responsible for
this abnormality, they explained. It appears that
during ultrafiltration, alterations occur which re-
lease or make available previously bound magne-
sium, they said.

Since the interfering substances are not ultra-
filterable, they are of high molecular weight, the
researchers said.

Although the significance of this finding remains
to be determined, it appears that the availability
of magnesium to activate certain enzymes linked
to muscle contraction “might well be a factor” in
the development of muscular dystrophy, they said.

In recent years, new impetus has been given the
study of metal ions in health and disease by the
increasing recognition of their important influences
upon activities of enzymes, they said.

Childhood MD, one of four types of muscular
dystrophy, begins in early childhood, is inherited
and almost always affects males. The disease affects
the pelvic muscles first and progresses rapidly.

SEEKS PHYSICIANS

for Psychiatric and General Medical
assignments in State facilities of the De-
partments of Mental Hygiene, Correc-
tions, Youth Authority.

Offering liberal salaries, a variety of
professional placement, and selection of
locale. No written examination. Inter-
views in San Francisco and Los Angeles
twice monthly.

Write for details to:

Medical Personnel Services,

Dept. SS,

State Personnel Board,

801 Capitol Avenue,

Sacramento, California

CALIFORNIA MEDICINE

MEDICINE

OFFICIAL JOURNAL OF THE CALIFORNIA MEDICAL ASSOCIATION
© 1 962, by the California Medical Association

Volume 97

JULY 1962

Number 1

Nonpolioviruses and Paralytic Disease

ROBERT L. MAGOFFIN, M.D., and

EDWIN H. LENNETTE, M.D., Ph.D, Berkeley

The work of Enders and associates7 published
in 1949 showing that polioviruses could be prop-
agated in vitro in cultures of various non-neural
tissues opened the way to the development simul-
taneously of practical methods for the laboratory
diagnosis of poliomyelitis and of formalin-in-
activated poliovirus vaccines (Salk type) . These
two developments led in turn to the increasing
recognition of illnesses diagnosed clinically as
paralytic poliomyelitis in which laboratory evidence
of poliovirus infection could not be found and
other viral infections were implicated.

This communication will review briefly some of
the recorded observations implicating various “non-
polioviruses” in paralytic disease and summarize
the results of virologic studies of cases of clinical
paralytic poliomyelitis made in this laboratory
since 1956. In this context, the term “paralysis” is
used broadly, as is commonly done in the clinical
diagnosis of poliomyelitis, to include any clearly
demonstrable weakness of localized muscle groups,
as opposed to generalized weakness that persists
after the acute febrile phase of illness has subsided.
It is apparent that this liberal definition includes
instances of transient weakness which may be of

Submitted March 26, 1962.

From the Viral and Rickettsial Disease Laboratory, California State
Department of Public Health, Berkeley 4, California.

Some of the studies which form the basis of this report were con-
ducted in this Laboratory, and were supported by a grant (E-1475)
from the National Institute of Allergy and Infectious Diseases, Na-
tional Institutes of Health, Public Health Service, U. S. Department
of Health, Education, and Welfare.

• A number of nonpolioviruses have been im-
plicated as the probable etiologic agents of para-
lytic illness clinically resembling poliomyelitis,
including certain immunotypes of Coxsackie
group A, Coxsackie group B, and ECHO viruses,
and the viruses of mumps, herpes simplex and
arthropod-borne encephalitides. A number of
well documented cases provide evidence that
some of these viruses may on occasion be the
causative agents of severe, even fatal, myelitis,
bulbomyelitis or encephalomyelitis, but they
have been associated much more frequently
with cases of “poliomyelitis” in which there has
been slight to moderate paresis. In the aggregate,
various “nonpolioviruses” have been encoun-
tered in approximately 10 per cent of the pa-
tients with clinical poliomyelitis studied, but it is
uncertain how many of these cases may repre-
sent coincidental infections not causally related
to the current illness.

no permanent consequence to the patient, and that
further characterization of paralysis with respect
to extent and duration is needed to evaluate the
seriousness of disability which may ensue.

Viral infections to be considered in
paralytic illnesses

Common Exanthemas of childhood. Involvement
of the central nervous system (CNS) associated
with measles (rubeola), rubella and chickenpox
may take diverse forms, but the clinical features
are most commonly those of diffuse or multifocal

VOL. 97, NO. 1 • JULY 1962

encephalitis or encephalomyelitis, including such
signs as irritability, convulsions, drowsiness or
coma, confusion, aphasia and ataxia.22,24,31 Thus
these infections are not commonly considered in
the clinical category of paralytic disease. However,
in rare cases of post-measles CNS disease, signs of
spinal cord involvement have been predominant,31
and the occurrence of cranial nerve palsies or
respiratory center involvement may in some cases
simulate bulbar poliomyelitis. The incidence of
post-infectious encephalomyelitis following the com-
mon childhood exanthemas is given in a recent
review24 as approximately 1 in 700 cases of measles,

I in 6.000 cases of rubella and 1 in 6,000 to 10,000
cases of chickenpox.

Herpes simplex. In primary infections, the herpes
simplex virus may involve the central nervous
system, giving rise to a varied clinical picture rang-
ing from benign meningitis to severe encephalo-
myelitis. Among the variable manifestations are
coma, convulsions, ocular palsies, paresis of muscle
groups and sensory changes.28 Ocular palsies or
spinal cord involvement may clinically suggest
poliomyelitis. CNS involvement may be the only
clinical manifestation of herpes virus infection or
may be accompanied by characteristic herpetic
lesions of the skin or mucous membranes. CNS
involvement is not known to be associated with
recurrent episodes of herpetic disease.

Mumps. The mumps virus is now recognized as
one of the most common etiologic agents of aseptic
meningitis or mild meningoencephalitis, character-
ized by headache, pleocytosis, signs of meningeal
irritation and varying degrees of drowsiness. Al-
though often referred to as a complication, this
clinical picture apparently results from direct in-
vasion of the CNS, at least of the meninges, as one
of the alternative sites of localization of the virus
in the course of mumps virus infection. Thus this
syndrome may accompany, follow, precede, or
occur without parotitis or other manifestations of
mumps virus infection and is commonly estimated
to occur in 5 to 10 per cent of all cases of clinical
mumps. In some instances the signs of meningitis
or meningoencephalitis may be accompanied by
muscle pain, tightness of the hamstrings and local-
ized paresis — resembling poliomyelitis. A series of

II cases of mumps virus infection initially diag-
nosed clinically as spinal paralytic poliomyelitis
was recently described in a report17 from this
laboratory. All the patients were children from 1 to
11 years of age. Four of the patients were referred
from the infectious disease service to secondary
hospitals for convalescent care because of persistent
muscle weakness and tightness. Also, in four in-
stances slight residual weakness was still detectable

on follow-up muscle examinations two to five
months after onset.

More severe neurologic involvement similar to
the demyelinating type of post-infectious encephalo-
myelitis has also been observed, though rarely, in
mumps virus infection.22,24

The enteroviruses. The family of human entero-
viruses now includes some 60 different agents, most
of which have come to light only within the last
ten years. There are unsettled questions regarding
ultimate classification, but the enteroviruses are
currently divided into four major groups: polio-
viruses (3 types), group A Coxsackie viruses (24
types), group B Coxsackie viruses (6 types) and
echo viruses (29 types). While it is convenient
to refer collectively to “Coxsackie viruses” or
“echo (entero-cytopathogenic human orphan)
viruses,” each virus type is antigenically distinct.
With the absence of commonly shared antigens, at-
tempts to identify infection with these agents by
means of antibody assays of paired serum speci-
mens from patients require a separate serologic
test for each type. Thus laboratory diagnosis of an
enterovirus infection generally rests upon recovery
and identification of the specific viral type aug-
mented by antibody assays for the type of virus
recovered.

CNS illnesses associated with
“nonpolio” enteroviruses

Aseptic meningitis or meningoencephalitis has
been associated with many types of Coxsackie and
echo viruses through epidemiologic, clinical and
laboratory observations, including recovery of a
number of virus types from the blood or spinal
fluid.8,14,34 Reports of more severe neurologic dis-
ease have been relatively uncommon but several
types of Coxsackie and ECHO viruses have been
implicated in illnesses resembling paralytic polio-
myelitis, ranging in severity from slight paresis to
severe and fatal bulbospinal disease, and also in
serious encephalomyelitic syndromes. Some of the
published observations relative to the role of Cox-
sackie and ECHO viruses in neurologic diseases
are outlined in Table 1.

The most extensive observations have concerned
Coxsackie virus, type A7. Several strains of this
virus were isolated in Russia in 1952 from two
patients with apparent bulbospinal poliomyelitis,
and this agent was considered for a time to be
“type 4 poliovirus.” Subsequent study showed it to
be immunogenically similar to American strains of
Coxsackie A7.3 In the United States, one case of
clinical poliomyelitis in a three-year-old boy with
right lower facial weakness and paresis of the right
lower extremity caused by Coxsackie A7 was de-
scribed by Steigman.29 Grist,10 in Scotland, reported

CALIFORNIA MEDICINE

TABLE 1. — Association of Coxsackie and ECHO Viruses with Neurologic Disease

Virus Type Association with Neurologic Disease Ileferencesf

Coxsackie Group A:

A7 Recovered from feces of patients with spinal and bulbar paralysis; some 3,* 10, 14, * 29*

fatal cases. Described in Russia as poliovirus, type 4. Produced neuronal
lesions in monkeys.

A9 Recovered from feces of patients with predominantly mild spinal para- 11, 12, 14,* 18

lytic illnesses; occasionally severe paresis.

Other types A2 recovered from CNS in infant deaths. A4 and A14 produced neuronal 3,* 4, 8*

lesions in monkeys. Possible synergism between other Group A viruses
and poliovirus?

Coxsackie Group B:

B2-B5 Recovered from feces of patients with mild to moderate spinal paralytic 3,* 12, 14,* 18, 21, 29*

illnesses in which poliovirus was excluded.

B2, B3, B4 Recovered from brain and/or spinal cords of infants with encephalo- 2,15*

myelitis and myocarditis. B2 produced neuronal lesions in monkeys.

B3 Recovered from spinal cord of patient with fatal spinal paralytic disease. 12

Echo Viruses:

E2 Recovered from spinal cord of patient with fatal bulbo-respiratory 29*

disease.

E4 Recovered from feces in sporadic cases of mild paresis. 11

E6 Recovered from feces, occasionally spinal fluid, of patients with mild 1, 13, 14,* 16, 25, 33, 34*

paresis; from spinal fluid of one patient with severe transient paralysis
(Guillain-Barre Syndrome). Caused paresis in monkeys.

E9 Recovered from feces of patients with mild paresis; from spinal fluid of 9, 14,* 19,27,32,33,34*

one patient with moderate residual paresis, one case of cerebellar ataxia
and from medulla of infant.

Ell Recovered from feces of patients with moderate to severe paresis; one 12,30

fatal bulbo-spinal case confirmed by virus isolation and antibody titer
rise.

Other types Many types (e.g., 1, 2, 3, 4, 6, 10) have occasionally produced focal neu- 3,* 35

ronal degeneration in infected monkeys, though often without evident
neurological signs.

* Review articles.

tThis table was compiled from selected references immediately available to the authors and is not presented as a complete bibliography.

the recovery of Coxsackie A7 virus from 33 pa-
tients with aseptic meningitis or suspected polio-
myelitis, seven of whom had some degree of para-
lysis, and one of whom, an infant, died. Coxsackie
virus A9 has been recovered from the feces of pa-
tients with mild to moderate paralysis for which no
other etiologic agent was found.1112'18,21 Although
other group A Coxsackie viruses have not been di-
rectly implicated to date in paralytic illnesses, A2
has been recovered from the CNS of infants who
died, and types A4 and A14 as well as A7 have
caused extensive neuronal lesions in monkeys.3,8
Also, the simultaneous recovery of Coxsackie A
viruses and poliovirus from poliomyelitis patients in
a number of studies has suggested the possibility of
a synergism between these agents in the causation of
paralysis when infections are concurrent.3 Experi-
mental support for this hypothesis was provided by
Dalldorf and Wiegand,4 who showed that in mon-
keys inoculated with an attenuated strain of type 1
poliovirus anterior horn cell lesions developed when
Coxsackie A7 or A14 infection was superimposed
five days later, whereas none of these virus strains
induced paralysis when inoculated singly.

Of the six Coxsackie group B viruses, four
types (B2-B5) have been repeatedly recovered

from the feces in cases of clinical paralytic
poliomyelitis with slight to moderate paresis in
which evidence of poliovirus infection was lack-
ing.11,12,18,21 Steigman29 recovered B5 virus from a
child with persistent residual paresis. Kalter12
recovered Coxsackie B3 virus from the spinal cord
of a five-year-old girl who died after a fulminating
clinical course of bulbospinal poliomyelitis. Also
several types of group B viruses have been re-
covered from the brain or the spinal cord as well
as from the heart and other tissues of small infants
who died of generalized Coxsackie virus infection.15
In these infections of infants myocarditis usually
was dominant in the clinical picture but signs of
encephalomyelitis have been noted in about one
third of the cases reported, and focal histologic
lesions of the brain, brain stem and spinal cord
have been found in a high proportion of the cases
studied.

With respect to the ECHO viruses, several types
(types 4, 6, 9, 11, and 16) have been responsible
for outbreaks of aseptic meningitis, and several
additional types have been associated with spo-
radic cases of this syndrome.14,34 At least eight
types, namely, 2, 4, 5, 6, 9, 11, 12 and 18, have
been isolated from the spinal fluid during ill-

VOL. 97. NO. 1 • JULY 1962

TABLE 2. — Virologie Findings in Cases of Clinical Paralytic Poliomyelitis by Vaccination Status . California 7956-7960

Per Cent of Patients, by Laboratory Result

Doses Number Nonpoliovirus

Vaccine of Polio- j Total 1 Incon-

( Salk) Patients virus . Coxsackie ECHO Other Nonpolio 1 elusive Negative

Total 706* 62 i 4 3 3 10 i 18 10

None 260 80 j 2 <1 2 4 ' 10 6

1 dose 122 70 i 2 2 6 9 . \ 15 6

2 doses 177 50 i 6 7 3 17 i 21 12

3+ doses 139 37 | 9 4 2 15 j 29 19

*Total includes 8 patients whose vaccination status was unknown.

ness.5,6,14,26 In addition to the usual manifestations
of the aseptic meningitis syndrome, mild to mod-
erate paresis of scattered muscle groups has been
noted in several types of ECHO virus infections.
Disability has usually been minor and transitory,
although in some cases mild weakness has persisted
for three to six months or longer. Minor degrees
of paresis have been linked to echo virus types l,23
4, 11 6, 13,16,33 9, 9,27,33 and 11. 12 There are several
reports, however, of more serious paralytic and
encephalomyelitic disease attributed to echo vi-
ruses. Parker and associates25 recently reported the
recovery of ECHO 6 virus from the feces and spinal
fluid of a patient with severe paralysis, clinically
classified as the Landry-Guillain-Barre syndrome.
Steigman29,30 has described two fatal cases of
apparent bulbospinal poliomyelitis, both in two-
year-old children, with flaccid paralysis of the
extremities and respiratory insufficiency requiring
tracheotomy and placement in a respirator. The
spinal cord of one child yielded ECHO 2 virus,
and echo 11 virus infection was present in the
other case. Another fatal illness, seen by Verlinde32
in Holland, occurred in an eight-month-old infant
who died after 24 hours of fever and coma; ECHO
9 was recovered from the medulla. In an extensive
epidemic of echo 9 infections in Milwaukee in
1957, Sabin and others27 observed that among 213
patients in hospitals (predominantly with aseptic
meningitis) one 20-year-old girl at first was thought
to have spinal paralytic poliomyelitis because of
spasm of the spinal musculature and weakness of
the hips which required the use of crutches for
about two months. Five patients had signs sug-
gesting involvement of the cerebellum and vestib-
ular nuclei — such as vertigo, loss of balance,
nystagmus and facial grimacing. Cerebellar ataxia
was subsequently observed by McAllister19 in a
five-year-old boy whose spinal fluid contained ECHO
9 virus. In experimental infections, ECHO types 6
and 16 produced paresis in macacus monkeys,1 and
focal neuronal lesions not clinically evident have
been noted in occasional monkeys infected with
various ECHO viruses including types 1, 2, 3, 4,
6, 10, 13.35

Frequency of association of nonpolioviruses
with paralytic disease

In attempting to assess the frequency of associa-
tion of various nonpolioviruses with paralytic ill-
ness in California on the basis of virologie studies
made in our laboratory since 1956, it has been
apparent that the results varied appreciably with
respect to the patient’s age, immunizations against
poliomyelitis and the severity of paralysis.

Age. In etiologic studies of clinical paralytic
poliomyelitis in California,18 poliovirus was re-
covered from about 80 per cent of the patients
under five years of age, as compared with 60 to 65
per cent of older children and adults. Brown and
associates2 noted a generally similar age trend in
the recovery of poliovirus from patients in the
1958 epidemic of poliomyelitis in Detroit. Cox-
sackie and echo virus infections were also en-
countered more frequently in paralytic illnesses in
children under 15 years of age but there was no
pronounced grouping in any age bracket within
this age range.18

Immunization with poliovirus vaccine (Salk).
Poliovirus has been less often recovered and other
viral infections more frequently found in cases of
paralytic illness in patients immunized against
poliomyelitis than in the nonimmunized. This is
illustrated in Table 2, which gives the virologie
findings in 706 cases of suspected paralytic polio-
myelitis studied in this laboratory from 1956-1960.
Either by recovery of the virus or demonstration of
a significant antibody titer rise, poliovirus infection
was confirmed in 80 per cent of the patients in the
nonvaccinated group, in about 70 per cent of
those who had received one dose of vaccine, in 50
per cent of those who had two doses, and in less
than 40 per cent of those who had three or more
doses. Conversely, the frequency of nonpoliovirus
infections increased from less than five per cent in
the nonvaccinated group to 15 per cent in the
three-dose group. Although differing in actual per-
centages, the findings of Brown and associates2 in
the Detroit epidemic in 1958 showed a fairly sim-
ilar pattern of decrease in the proportion of

CALIFORNIA MEDICINE

TABLE 3. — Virol ogle Findings In 802 Cases of Clinical Poliomyelitis According to Type and Severity of Paralysis 1

Per Cent Distribution

Spinal

Paralytic

Bulba

Bulbo-

ir and
■Spinal

Findings

Nonparalyti<

; Minimal

Mild

Moderate

Severe

Mild-Mod.

Severe

Total, per cent

toot

100

Poliovirus

Doubtful evidence of poliovirus

Negative

Nonpoliovirus

Poliovirus and nonpoliovirus

Number of cases, total 802

444

•Modified from Magoffin, R. L., Lennette, E. H.,
J.A.M.A., 175:269-278, Jan. 28, 1961.

■{"Percentages are rounded independently and may

Hollister, A. C.,
not add to total.

and Schmidt,

N. J.: An etiologic

study of cl

inical paralytic poliomyelitis.

laboratory-confirmed poliomyelitis cases among
immunized patients.

Severity of paralysis. The relatively infrequent
implication of nonpolioviruses in cases of severe
paralytic disease suggested by the foregoing review
of published reports is illustrated by the experience
in California, which is summarized in Table 3.
These data, from a study of clinical poliomyelitis
previously published,2 show that poliovirus and
nonpoliovirus infections were each fairly often (12
per cent to 36 per cent) associated with “non-
paralytic poliomyelitis” or with “paralytic cases”
in which there was only minor paresis. However,
with increasing degrees of paralysis or with bulbar
involvement, the frequency of nonpoliovirus infec-
tions declined sharply. The higher frequency of
nonpoliovirus infections in cases in which there
was slight to moderate paresis provides supporting
evidence of a causal relationship to this type of
illness; if these agents merely represented coinci-
dental infections, a more equal distribution in all
categories of severity would be expected.

The proportion of laboratory-confirmed polio-
myelitis cases became larger with the increasing
severity of paresis and with the appearance of
bulbar signs, reaching a maximum of about 85 per
cent. Even in the categories of severe spinal para-
lytic or bulbospinal disease, however, there were
some cases, particularly in the vaccinated patients,
in which no laboratory evidence of poliovirus or of
any other infection was elicited.

Overall incidence of nonpoliovirus infections.
Without respect to the variables of age, vaccination
status, and severity of paresis, the overall occurrence
of nonpolioviruses in 706 cases of paralytic disease
studied in this laboratory from 1956 to 1960 is
summarized in Table 4. For comparison, the find-
ings in 1,259 cases clinically classified as non-
paralytic poliomyelitis or aseptic meningitis are
also shown. In the group of paralytic cases, polio-
virus infection was confirmed in 62 per cent; in
18 per cent it was neither confirmed nor ruled out

TABLE 4. — Vlrologic Findings in Cases of Clinical Paralytic
Poliomyelitis and Aseptic Meningitis, California 1956-1960

Nonparalytic

Paralytic Poliomyelitis,

Laboratory Poliomyelitis Aseptic Meningitis

Results Number Per Cent Number Per Cent

Totals 706 100 1,259 100

Poliovirus 437 62 85 7

Other enteroviruses.. 53 7 488 39

Coxsackie A 2 <1 23 2

Coxsackie B 29 4 342 27

echo 22 3 123 10

Mumps 13 2 80 6

Herpes simplex 6 1 8 <1

SLE, WEE 1 <1 7 <1

Dual infections 0 0 16 1

Inconclusive 125 18 305 24

Negative 71 10 270 21

(i.e. virus was not recovered and serologic tests
were inconclusive) ; and in 10 per cent results of
all tests were negative. In 73 cases (about 10 per
cent) evidence of a current infection with some
other virus was elicited. These other viruses in-
cluded a Coxsackie group B virus in 29 cases (4
per cent), a Coxsackie group A virus in three
cases (less than one per cent), an ECHO virus in
22 cases (3 per cent), the mumps virus in 13 cases
(2 per cent), the virus of herpes simplex in six
cases (1 per cent) and the St. Louis encephalitis
virus in one case. Altogether, enteroviruses other
than poliovirus were found in about 7 per cent, and
nonenteric viruses in about 3 per cent of the
paralytic illnesses. In cases clinically diagnosed as
nonparalytic poliomyelitis or aseptic meningitis,
infections with group B Coxsackie viruses, echo
viruses, or the mumps virus were each found in a
much higher proportion of the illnesses, often ex-
ceeding poliovirus infections.

The specific immunotypes of viruses encountered
each year in paralytic cases are shown in Table 5.
In keeping with the pattern commonly found in
the United States, type 1 poliovirus infections (360
cases) greatly exceeded type 3 infections (72
cases), and type 2 infections were infrequent (five
cases). The other enteroviruses encountered in-

VOL. 97, NO. 1 • JULY 1962

TABLE 5. — Specific Viruses Associated with Cases of Clinical
Paralytic Poliomyelitis. California 7956-1960

Type of
Virus

Number

of Patients, by Year

Total

1956 1957

1958

1959 1960

Cases studied

.. 706

272

103

102

138

Poliovirus

... 437

Type 1

... 360

156

Type 2

... 5

Type 3

... 72

Coxsackie virus

... 31

Type A9

... 1

Type A16

... 1

Type B2

... 8

Type B3

... 2

Type B4

Type B5

... 11

Type B6

... 1

Echo virus

.. 22

Type 4

... 7

Type 6.

... 4

Type 9

... 2

Type 11

... 1

Type 13

... 1

Type 14

... 3

Untyped

- 4

Mumps

... 13

Herpes simplex

... 6

St. Louis encepli

Total:

Nonpolioviruses

No. of patients..

... 73

Per cent

... 10%

11%

17%

11%

eluded Coxsackie virus types A9, A16, B2, B3, B4,
B5 and B6, echo virus types 4, 6, 9, 11, 13 and 14,
and several unidentified ECHO types. With the ex-
ception of Coxsackie virus types A16 and B6, and
ECHO virus types 13 and 14, all of these viruses
previously have been associated by various inves-
tigators with cases of paralytic illnesses.

COMMENT

The ubiquitous distribution of Coxsackie and
ECHO viruses is well known. These agents have
frequently been recovered from apparently healthy
persons and have been associated with various
clinical syndromes in addition to the disorders of
the central nervous system discussed herein. Thus
it must be emphasized that the demonstration of
infection with one of these agents during the course
of illness in a patient with a cns disorder does not
constitute proof of a causal relationship. Etiologic
significance in each case must be weighed against
the possibility of an adventitious infection unrelated
to the current illness.

In our opinion, the reports of several well docu-
mented instances of recovery of the virus from
the brain or spinal cord of man and the demonstra-
tion of neurotropic properties in experimentally in-
fected animals (see above) provide convincing
evidence that certain types of Coxsackie and ECHO
viruses have the capacity to produce neurologic dis-
ease which may clinically simulate poliomyelitis.

However, factors such as the possibility of coinci-
dental infection and variability in the frequency
of infection with respect to age, severity of disease
and previous immunization of the patient against
poliomyelitis make it extremely difficult to estimate
the overall contribution of known types of “non-
polioviruses” to the occurrence of paralytic disease.
If etiologic significance were assumed in every
instance, in the recent experience of this laboratory,
as described above, viruses other than poliovirus
might account for about 10 per cent of the illnesses
considered clinically to be cases of paralytic polio-
myelitis, predominantly cases with slight degrees of
paresis. A similar or lesser frequency of nonpolio-
virus infections associated with paralytic illness has
been observed by other investigators.2,12,23 Any cor-
rection for coincidental infections would, of course,
reduce the number of assumed etiologically signi-
ficant infections. Thus, while there is substantial
evidence that viruses other than poliovirus are the
causative agents of illnesses clinically simulating
paralytic poliomyelitis, nonpolioviruses have not
been demonstrated to be major contributors to
the overall occurrence of paralytic diseases in re-
cent years.

Acknowledgments: Many individuals contributed to the
clinical and laboratory studies described herein. The authors
particularly wish to acknowledge the assistance of Dr. Henry
Renteln of the Bureau of Communicable Diseases, Califor-
nia State Department of Public Health, the cooperation
of local health officers throughout California in obtaining
clinical records and specimens, and the technical contribu-
tions of Dr. Nathalie Schmidt, Miss Anna Wiener, Mr. Tak
Shinomoto, Mrs. Florence Jensen and Mrs. Margaret Ota.

State Department of Public Health, 2151 Berkeley Way, Berkeley
4 (Lennette).

REFERENCES

1. Arnold, J. H., and Enders, J. F. : Disease in Macacus
monkeys inoculated with echo viruses, Proc. Soc. Exper.
Biol, and Med., 101:513-516, July 1959.

2. Brown, G. C., Lenz, W. R., and Agate, G. R.: Labora-
tory data on the Detroit poliomyelitis epidemic — 1958,
J.A.M.A., 172:807-812, Feb. 20, 1960.

3. Dalldorf, G. : The enteroviruses and paralytic disease.
Chapter in Viral Infections of Infancy and Childhood, Rose,
H. M., ed., Paul B. Hoeber, Inc., New York, 1960, pp.
128-144.

4. Dalldorf, G., and Weigand, H.: Poliomyelitis as a com-
plex infection, J. Exper. Med., 108:605-616, Nov. 1958.

5. Eckert, G. L., Barron, A., and Karzon, D. T.: Aseptic
meningitis due to echo virus type 18, A.M.A. J. Dis. Child.,
99:1-3, Jan. 1960.

6. Elvin-Lewis, M., and Melnick, J. L. : Echo 11 virus
associated with aseptic meningitis, Proc. Soc. Exp. Biol,
and Med., 102:647-649, Dec. 1959.

7. Enders, J. F., Weller, T. H., and Robbins, F. C. : Cul-
tivation of the Lansing strain of poliomyelitis virus in vari-
ous human embryonic tissues, Science, 109:85-87, Jan. 28,
1949.

8. Expert Committee on Poliomyelitis, Third Report,
W.H.O.: Technical Report Series No. 203, Geneva, 1960.

9. Foley, J. F., Chin, T. D. Y., and Gravelle, C. R.: Para-
lytic disease due to infection with echo virus type 9. Report

CALIFORNIA MEDICINE

of a case with residual paralysis, N.E.J.M., 260:924-926,
April 30, 1959.

10. Grist, N. R.: Isolation of Coxsackie A7 virus in Scot-
land, Lancet, vol. 1, 1960, p. 1054, May 14.

11. Hammon, W. McD., Yohn, D. S., Ludwig, E. H.,
Pavia, R., and Sather, G. E.: A study of certain nonpolio-
myelitis and poliomyelitis enterovirus infections, J.A.M.A.,
167:727-734, June 7, 1958.

12. Kalter, S. S., Page, M., and Suggs, M.: Laboratory
and epidemiologic results on specimens submitted for po-
liomyelitis diagnosis. Paper presented to American Associa-
tion of Immunologists, 42nd Annual Meeting, Philadelphia,
April 1958, Summary in CDC Poliomyelitis Surveillance
Report (Atlanta) No. 138, April 7, 1958.

13. Karzon, D. T., Barron, A. L., Winkelstein, W., Jr.,
and Cohen, S.: Isolation of echo virus type 6 during out-
break of seasonal aseptic meningitis, J.A.M.A., 162:1298-
1302, Dec. 1, 1956.

14. Kibrick, S. : The role of Coxsackie and echo viruses
in human disease, Med. Clinics N. Amer., 43:1291-1308,
Sept. 1959.

15. Kibrick, S., and Benirschke, K.: Severe generalized
disease (encephalomyocarditis) occurring in the newborn
period and due to infection with Coxsackie virus, Group B,
Pediatrics, 22:857-875, Nov. 1958.

16. Kibrick, S., Melendez, L., and Enders, J. F.: The
clinical associations of enteric viruses with particular ref-
erence to agents exhibiting properties of the echo group,
Ann. N. Y. Acad. Sci., 67:311-325, April 19, 1957.

17. Lennette, E. H., Caplan, G. E., and Magoffin, R. L. :
Mumps virus infection simulating paralytic poliomyelitis.
A report of 11 cases, Pediatrics, 25:788-797, May 1960.

18. Lennette, E. H., Magoffin, R. L., Schmidt, N. J., and
Hollister, A. C. : Viral disease of the central nervous sys-
tem. Influence of poliomyelitis vaccination on etiology,
J.A.M.A, 171:1456-1464, Nov. 14, 1959.

19. McAllister, R. M., Hummeler, K., and Coriell, L. :
Acute cerebellar ataxia. Report of a case with isolation of
type 9 echo virus from the cerebrospinal fluid, N.E.J.M.,
261:1159-1162, Dec. 3, 1959.

20. Magoffin, R. L., Lennette, E. H„ Hollister, A. C., and
Schmidt, N. J.: An etiologic study of clinical paralytic po-
liomyelitis, J.A.M.A., 175:269-278, Jan. 28, 1961.

21. Magoffin, R. L., Lennette, E. H., and Schmidt, N. J.:
Association of Coxsackie viruses with illnesses resembling

mild paralytic poliomyelitis, Pediatrics, 28:602-613, Oct.
1961.

22. Meade, R. H. Ill: Common viral infections in child-
hood, Med. Clinics N. Amer., 43:1355-1377, Sept. 1959.

23. Meyer, H. M., Jr., Johnson, R. T., Crawford, I. P.,
Dascomb, H. E., and Rogers, N. G.: Central nervous system
syndromes of “viral” etiology, Am. J. Med., 29:334-347,
Aug. 1960.

24. Miller, H. G., Stanton, J. B., and Gibbons, J. L.:
Parainfectious encephalomyelitis and related syndromes,
Quart. J. Med. (Oxford) , 25:428-505, 1956.

25. Parker, W., Wilt, J. C., Dawson, J. W., and Stackiw,
W.: Landry-Guillain-Barre syndrome — the isolation of echo
virus type 6, Canad. Med. Assn. J., 82:813-815, April 1961.

26. Sabin, A. B.: Role of echo viruses in human disease,
in Viral Infections of Infancy and Childhood, Rose, H. M.,
ed., Paul B. Hoeber, Inc., New York, 1960, pp. 78-93.

27. Sabin, A. B., Krumbiegel, E. R., and Wigand, R.:
Echo type 9 virus disease, A.M.A. J. Dis. Child., 96:197-
219, Aug. 1958.

28. Scott, T. F. Me.: The herpes virus group. Viral and
Rickettsial Infections of Man, 3rd ed., Rivers, T. M., and
Horsfall, F. L., Jr., editors, J. B. Lippincott Co., Philadel-
phia, 1959, pp. 757-772.

29. Steigman, A. J.: Poliomyelitic properties of certain
non-polio viruses: Enteroviruses and Heine-Medin disease,
J. Mt. Sinai Hosp. (N.Y.), 25:391-404, Sept. 1958.

30. Steigman, A. J., and Lipton, M.: Fatal bulbospinal
paralytic poliomyelitis due to echo 11 virus, J.A.M.A.,
174:178-179, Sept. 10, 1960.

31. Tyler, H. R.: Neurologic complications of rubeola
(measles), Medicine, 36:147-167, May 1957.

32. Verlinde, J. D.: Discussion in Poliomyelitis: Papers
and Discussions Presented at Fourth International Polio-
myelitis Conference, Philadelphia, J. B. Lippincott Co.,
1958, p. 235.

33. Wehrle, P. F., Judge, M. E., Parizeau, M. C., Carbo-
naro, O., Miller, M., and Zinberg, S.: Disability associated
with echo virus infections, N. Y. State J. Med., 59:3941-45,
Nov. 1, 1959.

34. Wenner, H. A.: The benign aseptic meningitides,
Med. Clinics N. Amer., 43:1450-1464, Sept. 1959.

35. Wenner, H. A., and Chin, T. D. Y.: Discussion of
Melnick, J. L., Echo Viruses, in Cellular Biology, Nucleic
Acids, and Viruses, Special Publications N. Y. Acad. Sci.,
5:384, 1957.

Human Renal Transplantation, II*

A Successful Case of Homotransplantation of the
Kidney Between Identical Twins

WILLARD E. GOODWIN, M.D., MATT M. MIMS. M.D., JOSEPH J. KAUFMAN, M.D.
RODERICK D. TURNER. M.D., RALPH GOLDMAN, M.D., WILLIAM BONNEY, M.D.,
FRANKLIN ASHLEY. M.D., RICHARD GLASSOCK, M.D., Los Angeles,
and PETER BRUCE. F.R.C.S., Melbourne

Renal transplantation between identical twins,
first performed successfully at the Peter Bent Brig-
ham Hospital in Boston in the fall of 1954 as an
exciting clinical experiment, is now an accepted
procedure, provided the indications are proper and
the donor is able to give the kidney without
jeopardizing his own life.8,10

Approximately 25 transplantations of kidneys be-
tween twins have been done since the first successful
case in Boston. There have been two successful
cases of kidney transplantation between non-identi-
cal twins.10 There have been no permanently suc-
cessful “takes” of kidney transplantation between
persons who are not twins, although Hamburger
of Paris recently described a successful case of
transplantation of a kidney from mother to son
with survival for more than a year.4 One of the
most recent reports of successful kidney trans-
plantation between identical twins is by Woodruff
of Edinburgh.10 An excellent recent review of the
literature was prepared by Menville and co-workers.6

To the present, so far as we could determine, only
three successful kidney homotransplantations have
been performed in the Western United States. The
first of these was done by Hodges, Murray and
Dunphy in Portland in October 1959.5 The second,
done at Stanford in August of 1960, was reported
by Cohn and coworkers.1

The purpose of this paper is to describe our
successful experience with homotransplantation of
a kidney between identical twins performed at the
University of California Medical Center in Los
Angeles on July 15, 1961. Our experiences with
non-twin renal homotransplantations are reported
elsewhere.2,3

REPORT OF A CASE

The subjects, A and B, were 41-year-old. mar-
ried. white, identical male twins. A, the sick twin,

•This is the second of three articles on this subject.2-3

From the Department of Surgery/Urology and the Department of
Medicine, University of California Medical Center, Los Angeles 24.

Presented before the Section on Urology at the 91st Annual Session
of the California Medical Association. San Francisco, April 15 to 18,
1962.

• Kidney transplantation between 41-year-old
twin men was carried out because of chronic
glomerulonephritis in one twin. The operation
was successful. Hypertension, edema and azote-
mia in the patient disappeared after operation
and both the donor and the recipient were well.

TABLE 1. — Renal Transplantation — Identical Twins I Preoperative
Studies I

Clinical Features

Twin A
( Recipient)

Twin B
( Donor)

Blood pressure 160/100 mm. mercury 115/65

Fundi Macular star Normal

Heart PMI MCL 5th interspace Normal

Renogram Decided impairment Normal

Electrocardiogram LVH Frequent

PVC’s

Hematocrit 26% 47%

Blood urea nitrogen 92.4 mg. % 12.5 mg. %

Serum creatinine 9.0 mg. % 1.0 mg. %

Urine protein 5.8 gm. /24° None

PMI = Point of maximal impulse; MCL = Midclavicular line; PVC =
Premature ventricular contraction; LVH = Left ventricular hypertrophy.

TABLE 2. — Renal Transplantation — Identical Twins I Preoperative
Renal Function I

Renal Functions

Twin A
( Recipient )

Twin B
(Donor)

Maximum specific gravity ...

1.016

1.021

Maximum osmolarity

332 mosm.

723 mosm.

Minimum specific gravity ...

1.010

1.000

Minimum osmolarity

262 mosm.

133 mosm.

Creatinine clearance

9.9 ml. /min.

119 ml./min.

Insulin clearance

10.0 mi./min.

105 ml./min.

Para-aminohippuric acid
clearance

19.9 ml./min.

492 ml./min.

Phenolsulfonphthalein 15'...

45%

total

77.5%

had no previous history of renal disease and no
symptoms until about September 1959 when al-
buminuria and pyuria were first noted at an
insurance examination. Subsequently, hypertension,
edema and azotemia developed. Since he had rather
far advanced renal disease and was known to have
an identical twin, he was referred to UCLA for
evaluation and consideration for renal homotrans-
plantation.

The patient was admitted for evaluation on three

CALIFORNIA MEDICINE

Figure 1. — Aortogram of donor. Note duplication of
left renal artery and small polar artery on the right side
with fairly normal right renal artery. This information led
to decision to use the right kidney of the donor.

occasions before transplantation was finally carried
out. On one admission digitalization was carried
out because of congestive heart failure due to
rapidly advancing hypertension. Laboratory studies
showed hemoglobin of 6.8 grams per 100 cc., serum
creatinine of 9.0 mg. per 100 cc., and he had mild
acidosis with a carbon dioxide combining power
of 17.9 mEq. An electrocardiogram was interpreted
as showing left ventricular hypertrophy (see Table
1).

Historical and photographic evidence suggested
that the twins were identical. In blood cross-match-
ing of the patient with his brother, ten groups
agreed exactly. Finger prints were almost identical
and crossgrafting of skin was successful. The twins
had identical defects in color vision, and both were
nonreactive to phenylthiocarbonamide.

The sick twin’s maximum urinary concentration
was 1.014 specific gravity with an osmolarity of
332. Addis counts showed 200,000 casts, 16 million
white blood cells and 298 million red blood cells.
Phenolsulfonphthalein excretion was 2 per cent in
two hours. Creatinine clearance was 9.9 cc. per
minute and inulin clearance was 10 cc. per minute.
Para-aminohippuric acid clearance was 19.9 cc. per
minute. A radioactive renogram showed decided
bilateral impairment (see Table 2). Renal biopsy
was not done. The clinical diagnosis was chronic
glomerulonephritis.

At the time of admission for transplantation on
July 14, Twin A had a serum creatinine level of
12.7 mg. per 100 cc.

After transfusion of several units of packed red
blood, the patient was considered ready for trans-
plantation of a kidney from Twin B, who meanwhile
had been studied extensively. Results of renal func-

Figure 2. — Technique of transplantation of right kidney
of donor to left iliac fossa of recipient. The renal artery,
which was posterior in the normal position, now lies
anteriorly to match the position of the hypogastric artery
in relation to the iliac vein. Note end-to-end anastomosis
of hypogastric artery to renal artery and end-to-side anas-
tomosis of renal vein to iliac vein.

tion studies were considered to be normal. On one
occasion he was found to have some red blood cells
in the urine. Because of concern over this, it was
decided to do a needle biopsy of his right kidney.
The biopsy was considered normal.

In order to check the blood supply of the kidneys
an aortogram was performed at the time of ad-
mission for evaluation. It showed that he had
duplication of the renal arteries on the left side
in such a way as to require a double anastomosis
of two relatively small arteries. On the right side
there was a large main renal artery and a tiny
lower polar artery which seemed insignificant
(Figure 1). Because of this, we elected to use the
right kidney of the donor and to place it in the left
hypogastric fossa of the recipient.

Operation

Two teams worked in adjacent rooms. One team
removed the right kidney from the donor and the
other team prepared the recipient. In general, the
technique followed was that originated by Hume
and Murray and the Peter Bent Brigham group, in
which the kidney is placed in the iliac fossa of the
recipient on the opposite side from which it was
removed from the donor.

Heparin was not used. After the kidney was re-
moved from the donor, it was placed on a cold,
wet towel in a bath of iced saline solution. It is
believed that refrigeration protects the kidney dur-
ing the period of ischemia.

The recipient was prepared by approaching the
left iliac area through a low transverse abdominal
incision. The left hypogastric artery was dissected

VOL. 97. NO. 1 • JULY 1962

Figure 3. — Postoperative intravenous pyelogram show-
ing transplanted kidney lying in the left iliac fossa.

free with all its branches, which were ligated and
transected. When it was demonstrated that the
donor kidney had in fact only one major artery,
the excess branches of the hypogastric artery were
excised; and end to end arterial anastomosis be-
tween the left hypogastric artery and the renal
artery was done. The renal vein was joined to the
left iliac vein, end to side (Figure 2).

Owing to technical difficulty caused by the pres-
ence of an arteriosclerotic plaque, the arterial anas-
tomosis had to be repeated twice. The total time of
renal ischemia was 106 minutes. However, the pro-
cedure was ultimately successful and a copious out-
put of urine began shortly after the blood supply
was restored — 375 cc. in the first twenty minutes.

The ureter was joined to the bladder by a tun-
nelling technique. A splinting ureteral catheter and
a cystostomy tube were brought out through the
suprapubic incision. The kidney was placed above
the bladder and to the left in the hypogastric fossa
behind the peritoneum (Figure 3). Before closure
was completed, the kidney was partially decapsu-
lated by making cruciate incisions in the capsule.
This was done to diminish the effects of postopera-
tive edema within the tight renal capsule. There
was minimal bleeding.

The initial postoperative course of both patients
was interesting. The recipient had pronounced di-

D*ys Z)a</s

pre-operative post-operative. -

— X -at -/•? _/ / i a a L. a in io /a ■»/■> A*r ■r/|

Chart 1. — Changes in serum creatinine and urine flow.

uresis with concomitant weight loss. He excreted
9550 cc. of urine from the ureteral catheter in the
first 24 hours. The serum creatinine fell from 12.7
mg. per 100 cc. immediately after the operation
to 9.3 mg. after four hours, 4.8 mg. after 18 hours
and 1.75 mg. per 100 cc. 72 hours after the pro-
cedure (Chart 1). Fluids and electrolytes were re-
placed intravenously according to serum and urine
determinations. Immediately after the operation
serum calcium was 4.1 mEq. per liter and phos-
phorus 11.3 mEq. Within 72 hours, the serum
calcium was 4.43 mEq. and the serum phosphorus
had fallen to 1.3 mEq. (Chart 1). Severe left flank
tenderness and fever developed in the recipient. It
was thought that the tenderness was due to obstruc-
tion of the remaining left ureter and kidney.
Phensolsulfonphthalein clearance from the trans-
planted kidney on the fourth postoperative day was
30 per cent in two hours. Later it rose to 50 per
cent.

Pulmonary infarction developed in both twins,
mild in the right lower lobe of the donor and more
extensive in the left lower lobe of the recipient.
Otherwise the donor’s recovery was uneventful.
Despite maintenance of anticoagulant therapy, deep
thrombophlebitis developed in the left leg of the
recipient, possibly related to obstruction of the iliac
vein during the time of transplantation. A wound
abscess developed and was subsequently drained.
The patient was discharged from the hospital in
good condition on August 17, 1961.

The recipient was readmitted on September 1, six
weeks after the transplantation. Both of his own
diseased kidneys were removed simultaneously by
means of a posterior approach with the patient in
the prone position. They were extensively damaged
with advanced glomerulonephritis.

CALIFORNIA MEDICINE

TABLE 3. — Renal Transplantation — Identical Twins (Recipient,
Before and After Transplantation I

Renal Functions

Preoperative

Postoperative

Maximum spec fic gravity...

1.016

1.020

Maximum osmolarity

332 mosm.

684 mosm.

Serum creatinine

9.0 mg. %

1.1 mg. %

Creatinine clearance

9.9 ml./ min.

56 ml. /min.

Phenolsulfonphthalein 15'...

15%

total

35%

Hematocrit

26%

48%

Urine protein

5.8 gm. /24°

0.1 gm. /24°

On the light side the twelfth rib was removed
for better exposure, and thus fortuitously the re-
cipient again resembled his identical twin brother,
whose twelfth rib was removed at the time of
nephrectomy when he gave the “donor kidney.”

Subsequently renal function studies showed the
function to be the same in the two kidneys, one in
each twin. The hypertension of the patient dis-
appeared.

The donor developed a peptic ulcer which re-
sponded to medical management. One may specu-
late as to the role of surgical stress in this event.

Both twins are now in excellent health and have
resumed their normal lives, and are back at work
in their photography shops. The prognosis of the
previously doomed patient should be excellent.

Department of Surgery/Urology, UCLA Medical Center, Los An-
geles 24 (Goodwin).

REFERENCES

1. Cohn, R„ Oberhelman, H., Jr., Young, J., and Holman,
H. : A successful case of homotransplantation of t he kidney
between identical twins, Am. J. Surg., 102:344-350, August
1961.

2. Goodwin, W. E., Kaufman, J. K., Mims, M. M., Turner,
R. D., Glassock, R. J., Goldman, R., and Maxwell, M. M.:
Human renal transplantation, I.: Clinical experiences with
six cases of renal homotransplantation, Proc. West. Sec.
Amer. Urol., San Francisco, April 23-26, 1962. (To be pub-
lished in J. Urol.) .

3. Goodwin, W. E., Mims, M. M., and Kaufman, J. J.:
Human renal transplantation, III: Technical problems en-
countered in six cases of kidney homotransplantation, Trans.
Amer. Assn. Genitourin. Surg., Skytop, Pa., May 9-11, 1962.
(To be published in J. Urol.) .

4. Hamburger, J., Kidney homotransplantation in France,
Proc. Fifth Internat. Tissue Homotranspl. Conf., New York
Acad. Sci., Feb. 8-10, 1962.

5. Hodges, C. V., Pickering, D., Murray, J. E., and Good-
win, W. E. : Successful kidney transplant with a 21/6-year
follow-up, Proc. West. Sec. Amer. Urol. Assn., San Fran-
cisco, April 23-26, 1962. (To be published in J. Urol.).

6. Menville, J. G., Schlegel, J. U., Pratt, A. M., II, and
Creech, 0. Jr.: Human kidney transplantation in identical
twins, J. Urol., 85:233-238, March 1961.

7. Merrill, J. P., Murray, J. E., Harrison, J. H., and
Guild, W. R.: Successful homotransplantation of the human
kidney between identical twins, J.A.M.A., 160:277, 1956.

8. Merrill, J. P., Murray, J. E., Harrison, J. H., Fried-
man, E. A., Dealy, J. B. Jr., and Dammin, G. J.: Successful
homotransplantation of the kidney between nonidentical
twins, N.E.J.M., 262:1251-1260, June 1960.

9. Murray, J. E., Merrill, J. P., and Harrison, J. H. : Kid-
ney transplantation between seven pairs of identical twins,
Ann. Surg., 148:343, 1958.

10. Woodruff, M. F. A., Robson, J. S., Ross, J. A., Nolan,
B., and Lambie, A. T.: Transplantation of a kidney from an
identical twin, Lancet, 280:1245-1249, June 1961.

VOL. 97, NO. 1 • JULY 1962

Criteria for Blood Transfusions

NOBLE A. POWELL JR., M.D., and D. GORDON JOHNSTON, M.D., Oxnard

The mortality from blood transfusions ranks with
that from appendicitis or anesthesia. Approximately
3,000 deaths result from the 3.5 million transfusions
given each year in the United States.2 In light
of the accumulating evidence of hazard, the pos-
sible benefit must be weighed against the danger
in each case. It is apparent therefore that more
exact definition of criteria for blood transfusion
should be established in the minds of physicians.
Recognition that there are medical and legal hazards
involved in the use of blood transfusions stimulated
the authors to make a study of the use of blood in a
100-bed community hospital over a two-year period.

Objectives of this project were: (1) To see how
often blood was transfused when it was not truly
essential: (2) to provide educational data to the
medical staff on the subject of indications and
dangers of blood transfusions; (3) to stimulate
the use of improved scientific methods as an aid
in the determination of the necessity for use of
blood transfusion; and (4) to establish mechanisms
of improved controls in the use of blood trans-
fusions if the study should show the controls were
needed.

METHOD

A survey of blood transfusions administered
in a 100-bed hospital over a one-year period
(1959-1960) was made by a two-man team us-
ing medical, surgical, obstetrical, anesthetic and
laboratory records from patients’ hospital charts.
One-unit, two-unit and three or more unit trans-
fusions were compared by incidence and apparent
need. Results of this survey were presented to the
hospital medical staff in conjunction with a program
designed to emphasize the indications, contraindi-
cations and complications of blood transfusions. A
second one-year survey (1960-1961) was then be-
gun and verbal references to this study were re-
peated at monthly hospital staff meetings to
maintain continued awareness of the problems re-
lated to blood transfusions. Results of the two
periods were then compared.

The transfusions of this study were divided into
three groups, one-unit, two units, and three or more

From the Department of Pathology, St. John's Hospital, Oxnard.

Pathologist and Director of Laboratories (Johnston).

Submitted November 27, 1961.

• A review of the use of blood transfusions used
in a small community hospital over a two-year
period revealed a high incidence of instances in
which the clinical record did not show essential
need for the procedure. Educational efforts in
hospital staff meetings resulted in some improve-
ment in this respect during the two-year period.
Of single unit transfusions given during the first
year, 80 per cent were deemed to have been
nonessential ; during the second year, 52 per
cent.

Methods which will reduce the use of blood
except when it is essential are (1) continuation
of staff education; (2) providing the staff with
accurate methods of measurement of blood vol-
ume and of monitoring blood loss; (3) use of a
separate blood transfusion chart in the patient’s
hospital record; and (4) establishment of a hos-
pital transfusion committee to review the criteria
in all cases in which blood is transfused.

units. Each of these groups was further subdivided
into three categories — emergency, homeostasis, and
nonessential — according to the apparent indications
for transfusion as determined from analysis of the
clinical records. The “emergency” group included
all transfusions deemed necessary to preserve life
by supporting circulating blood volume and/or en-
hancing oxygen-carrying capacity, and also all
transfusions used in cases of acute, uncontrolled
loss of blood in which the extent of the immediate
loss and the probable further loss could not be
estimated. Excluded from this group were cases in
which oxygen-carrying capacity was considered to be
adequate and the circulating volume could have been
restored by using plasma expanders. The cases
grouped under “homeostasis” included those in
which blood transfusion was not an emergency pro-
cedure but was necessary to maintain health, a
plasma expander being inadequate. This group in-
cluded use of blood in supporting patients with
uremia, leukemia or wasting and neoplastic diseases.
Cases in which a plasma expander could have been
used instead of blood if the circulating volume had
to be increased were included in the “nonessential”
group. This category also included cases in which
indications for blood transfusions were not stated
in the patient’s chart and were not recognized upon
review of the clinical record. Some 48 per cent of
the series were so classified.

CALIFORNIA MEDICINE

Number of Patients

10 20 30 40 50 60 70 80 30 100 110 120 130 140

r Non-essential >> //" > v 1 ” J ' ■ ’ 1 ’ ' 1 ' 1 ' ' ” 1 1 "j

V/////////,/Z //' S?z '///, ,///; /A/y//////Y^

Chart 1. — Transfusions in three categories (one unit, two units, three or more units) related to three classifica-
tions of need for blood (emergency, homeostasis, nonessential) as determined from review of records over a two-year
period.

RESULTS

In the first of the two years reviewed, single unit
transfusions made up 47 per cent of the total; in
the second year, 42 per cent. Of the single unit
transfusions, 9 per cent of the first year’s and 40
per cent of those in the second year were deemed
to have been of an “emergency” nature and there-
fore essential, indicating an improvement in stand-
ards for the use of blood transfusions between the
first year and the second. Improvement of this order
also occurred in the two-unit and in the three or
more unit groups. (See Chart 1.)

DISCUSSION

For the most part the justifiable purposes of blood
transfusions are: (1) To maintain or increase the
volume of circulating blood; (2) to improve or
maintain the oxygen-carrying capacity of circulating
blood; (3) to replace toxic circulating blood, i.e.,
exchange transfusion; and, (4) to enhance blood
coagulation. In most instances the use of blood for
maintaining or increasing the circulating volume
should be reserved for cases requiring two or more
units. It has been observed that acute losses of

1,000 to 1,500 cc. of blood in previously normal
adults can be compensated by use of plasma ex-
panders if bleeding can be stopped.7 Since spon-
taneous reestablishment of hemoglobin begins soon
after bleeding in most cases, the amount increasing
approximately 0.1 to 0.3 grams per 100 cc. per day,5
the patient can be expected to be considerably
improved by the time of discharge, without ever
having had blood by transfusion.

Some surgeons have expressed the view that
healing will be more rapid if hemoglobin levels are
maintained within the normal range, but the authors
know of no convincing evidence in support of this
belief. Many surgeons and anesthetists believe that
a long operation is in itself an indication for whole
blood transfusion, that all patients with symptoms of
shock and blood loss need whole blood and that it is
unsafe for a mildly anemic patient to have a major
operation without previous transfusion of blood to
elevate the hemoglobin. Many also believe they are
quite accurate in estimating the loss of blood during
an operation. In general, these are misconceptions.
Wilson and Adwan9 reported that of 100 consecutive
patients with benign ulcers of stomach, duodenum
or gastroenteric stoma undergoing elective partial

VOL. 97, NO. 1 • JULY 1962

gastrectomy for reasons other than recent severe
bleeding, only two required blood transfusion dur-
ing the operation and none needed it afterward.
Crosby1 indicated that if the volume of blood
is normal a hemoglobin level of 7 grams per 100
cc. is sufficient for tissue oxygenation in most situa-
tions during an operation. Macdonald4 remarked
that a patient with a hemoglobin concentration of 11
grams per 100 cc. before operation would usually
be safer in donating a pint of blood than in receiv-
ing one.

The question of the use of blood to improve oxy-
gen-carrying capacity in an anemic patient is greatly
complicated by the many variables that enter into
calculating the degree of anemia. While there are
differences in the specific needs of each patient,
physicians should acquaint themselves with the
“normal” hemoglobin values for various age groups
of each sex in their geographical area. For example,
the usual hemoglobin level for young housewives
in the sea level community dealt with in the present
study ranges between 10.5 and 13.5 grams per 100
cc. In young men of that age group it ranges from
12.5 to 16.0 grams per 100 cc. Judy and Price3
reported a mean hemoglobin content of 12.55 grams
per 100 cc. in 663 “normal” women in the Spokane,
Washington, area which is at an altitude of about
2,000 feet. It should be emphasized that a single
unit of blood will increase the hemoglobin only 1.0
to 1.5 grams per 100 cc.5

The possible benefit must be weighed against the
hazards — hepatitis, bacteremia, transfusion reac-
tion, allergic reaction, sensitization. Anemia not con-
nected with surgical operation or traumatic bleeding
is also sometimes an indication for transfusion.
However, again considering the hazards, it is often
advisable to allow enough time for hematopoiesis to
make up the deficit under appropriate therapy.
Indeed, transfusion is seldom necessary in the treat-
ment of “medical” anemia. The usual changes in
hemoglobin levels during and following pregnancy
should be borne in mind, for giving whole blood
in such circumstances may set the stage for subse-
quent transfusion reactions or erythroblastosis
fetalis. Special hazards attend the use of blood
transfusion to treat anemia in patients with such
complicating conditions as congestive heart failure,
myocardial infarction, hypertension and hepatic
coma.

Inaccurate hemoglobin determination can lead to
prescribing blood where it is not essential. In one
hospital where an error of 2.0 grams (low) was
being reported by the laboratory an estimated 1,000
patients in a one-year period were given transfusions
that otherwise would not have been prescribed.5

While office procedures for hemoglobinometry may
be adequate for screening, transfusion should not
be considered in any elective situation until hemo-
globin determinations have been carried out by a
laboratory using accurate standards and quality
control.

The use of plasma substitutes for colloidal main-
tenance of blood volume does not receive the atten-
tion it deserves. Sayman and Allen7 said that patients
requiring only one or two units of blood should
probably receive a colloidal substitute. Morton6 ob-
served from data obtained in a six months survey
that 34 to 72 per cent of single unit transfusions
had not been essential. He believed that blood had
been given without adequate reason: (1) To im-
prove wound healing; (2) to replace loss of blood
in small amounts; (3) to relieve emotional instabil-
ity; (4) because of hypotension clearly associated
with anesthetic or analgesic drugs; (5) during
operation, and, (6) before operation to patients
with anemia, most of whom had iron deficiency.

CONCLUSIONS

1. Further education is needed in the employ-
ment of blood transfusions.

2. A rapid, practical, inexpensive method for
determination of blood volume and to monitor
blood loss. This requirement is met in our laboratory
by the use of the “Volemetron,”'"8 employing radio-
active iodine-labeled albumin.

3. A standard blood transfusion chart should be
available for the patient’s hospital record. This is
necessary because often there is no adequate record
of data that later can justify the use of blood trans-
fusions. Although the need for this therapy may
have been apparent to the physician at the time,
the absence of an adequate record might result in a
dire legal complication should damage to the patient
result from the use of blood. The separate record
sheet may serve as a reminder to the physician of
the dangers of blood transfusion and also be of
value later should there be need to review the
record.

4. Hospitals should have transfusion review com-
mittees to: (a) review records for indications in
cases in which transfusions are used; (b) support
and encourage educational efforts in the proper use
of blood transfusions; and, (c) maintain vigilance
over laboratory methods of hemoglobinometry,
blood typing, cross-matching, and the handling and
identification of blood to insure accurate reports
and maximum safety from laboratory error.

St. John’s Hospital, 333 North "F" Street, Oxnard (Johnston).

*The "Volemetron," manufactured by the Atomium Corporation,
Waltham, Massachusetts.

CALIFORNIA MEDICINE

REFERENCES

1. Crosby, W. H.: Misuse of blood transfusion, Blood,
13:1198-1200, 1958.

2. Hirsh, B. D.: Responsibilities in blood transfusion,
Medico-Legal Digest, 1:21-26, 1960.

3. Judy, H. E., and Price, N. B.: Hemoglobin level and
red cell count findings in normal women, J.A.M.A., 167:
563-566, 1958.

4. MacDonald, I.: Editorial, Bulletin, L. A. Co. Med.
Assn., 91:57-58, March 16, 1961.

5. Mainwaring, R. L. : Hemoglobin levels and blood trans-
fusion, J. Mich. State Med. Soc., 59:286-287, 1960.

6. Morton, J. H.: An evaluation of blood transfusion prac-
tices on a surgical service, N.E.J.M., 263:1285-1287, 1960.

7. Sayman, W. A., and Allen, G. J.: Blood plasma and
expanders of plasma volume in the treatment of hemor-
rhagic shock, Surg. Clin, of N. Amer., 39:133-143, 1959.

8. Williams, J. A., and Fine, J.: Measurement of blood
volume with a new apparatus, N.E.J.M., 264:842-848, 1961.

9. Wilson, B. J., and Adwan, K. O.: A critical assessment
of the use of blood transfusions during major gastric opera-
tion, Arch, of Surg., 80:760-767, 1960.

VOL. 97. NO. 1

JULY 1962

Transfusions

Hazardous Acid-Base Changes with Citrated Blood

JOVITA M. SAN PEDRO, M.D., SEIZO IWAI, M.D.,

MITSUO HATTORI, M.D., and M. DIGBY LEIGH, M.D., Los Angeles

Although the extreme acidity of citrated blood is
well-known,1,6,7,11,12 the effect of this acidity on
the acid-base status of the recipient has not been
satisfactorily defined. Our interest was aroused by
the number of ill newborn and young infants who
received acid blood during surgical operation and
who had respiratory or metabolic acidosis or both.13
The present study is an attempt, for purposes of
comparison, to observe the acid-base changes in the
recipient’s blood during the administration of hepar-
inized blood.

That fresh heparinized blood is superior clinically
to stored blood is indicated by lower morbidity and
mortality following its use.4,16,19,20 In open heart
operations in which extracorporeal circulation is
used, heparinized blood has been useful in mini-
mizing cardiac complications and improving main-
tenance of acid-base balance.

METHODS

Rabbits ranging in weight from 2.5 to 2.95 kg.
(5.5 to 6.5 lb.) were used in this study. Under intra-
venous sodium pentobarbital anesthesia, 10 mg. per
pound of body weight, and local infiltration with 1
per cent lidocaine, intubation was accomplished
through tracheostomy to meet the adjustments in
ventilation planned for the experiment. The left
femoral vein and artery were cannulated for venous
and arterial pressure recording. The right femoral
artery was used for bleeding, transfusion and sam-
pling. A Gilson four-channel recorder was used to
monitor venous pressure, arterial pressure, electro-
encephalograms and electrocardiograms. The end-
tidal carbon dioxide concentration was continuously
sampled by attaching a catheter from the endo-
tracheal tube to a Beckman rapid infrared carbon
dioxide analyzer.5 A respirator of the Harvard
piston-type was used with room air when controlled
ventilation was employed. The pH was measured
with the Astrup microradiometer.3 From samples
equilibrated with known concentrations of carbon

From The Division of Anesthesiology, Department of Surgery,
Los Angeles Children's Hospital, the University of Southern California.

Submitted November 29, 1961.

• In a study of the acid-base changes in the
blood of rabbits during and following trans-
fusions of citrated blood and of heparinized
blood, it was observed that, with citrated blood,
pH decreased and carbon dioxide tensions rose.
With heparinized blood, the acid-base balance
was maintained within normal limits following
transfusions.

The potential hazards of rapid massive citrated
blood transfusions in the anesthetized patient
during operation must be kept in mind.

dioxide, standard bicarbonate, tension of carbon
dioxide (Pco2), buffer base and base excesses were
calculated from the Astrup nomogram.2’17

A sufficient interval was allowed between the
preparation of the animal and the actual experiment
to attain regular respirations, stable blood pressure
and cardiac rate.

Since respiration is an important and rapidly
responsive mechanism in the control of acid-base
balance, the transfusion studies were done under
varied conditions of ventilation. Animals in each
group were transfused during hyperventilation and
during spontaneous unassisted respiration. The
changes in respiration were related to the acid base
metabolism. The average respiratory rate, tidal vol-
ume (vt), and minute volume were compared with
the reported normal values for rabbits.9

For ease in collection and transfusion, 10 ml.
syringes were used. Appropriate amounts of acid-
citrate-dextrose (acd) solution per syringe were de-
termined according to the proportions recommended
by the American Red Cross (120 ml. of ACD to 500
ml. of whole blood) . Heparin syringes were prepared
by flushing the syringe with fresh heparin solution,
(10 mg. per ml.), and then filling the dead space
with heparin. Using an estimated blood volume
(ebv ) of 57.3 ml. per kg. of body weight,8 each
animal was bled from the femoral artery in an
amount equal to 30 to 40 per cent of its EBV. In
order to avoid severe changes in the acid-base status
from prolonged shock, no more than three to five
minutes was permitted to elapse between bleeding
and transfusion.

CALIFORNIA MEDICINE

Transfusions were also given arterially. Arterial
blood samples were drawn in heparinized 1 ml.
syringes (1) before blood was removed, (2) after
bleeding, (3) before transfusion, (4) immediately
after transfusion and (5) every ten minutes there-
after for 40 minutes. From data in Table 1 it is
apparent that the heparin solution in the sampling
syringes was less acidotic than acd solution.

The four categories of experiments and the condi-
tions under which citrated blood and heparinized
blood was given were as follows:

Group I. Rapid ACD blood transfusions
Hyperventilation with room air
Group II. Rapid heparinized blood transfusions
Hyperventilation with room air
Group III. Rapid ACD blood transfusions

Spontaneous unassisted respiration
Group IV. Rapid heparinized blood transfusions
Spontaneous unassisted respiration

RESULTS

Group I. Rapid ACD blood transfusion; hyperven-
tilation with room air.

(The subjects were five rabbits with an average
weight of 2.72 kg. (6.0 lb.) prepared in the manner
already described. Hyperventilation to approxi-
mately one and a half to two times the resting
minute volume was produced. Minute volume (mv)
was determined from the respiratory rate, and tidal
volume was measured with a British Oxygen Com-
pany spirometer. Relaxation was obtained when
necessary with intramuscular succinylcholine.)

Chart 1 shows that the average blood pressure,
standard bicarbonate, Pco2, and pH values from
each animal were quite consistent.

Shortly before the rabbits were bled, the average
pH was 7.468, Pco2 33 mm. of mercury, standard
bicarbonate 12 mEq. per liter. Blood pressure de-
clined as the total blood volume diminished. The
end-tidal C02 tracings (Chart 2) reflected changes
in the pulmonary circulation as the blood volume
diminished — that is, low end-expired C02 indicated
reduced cardiac output.1415 Blood pressure (Chart
1) varied directly with blood volume throughout the
experiment, being normal before bleeding and re-
turning to normal with restoration of the blood
volume.

Immediately after transfusion with citrated blood,
arterial Pco2 rose to 52 mm. of mercury, pH de-
clined to 7.25 and standard bicarbonate to 9.4 mEq.
per liter. Three minutes later, the Pco2 dropped to
35 mm. Hg. and the pH increased to 7.31. Within
approximately 40 minutes, Pco2, pH and standard
bicarbonate returned to control values. Immediately
after the administration of citrated blood, end-tidal

TABLE 1. — Effect of acld-cltrate-dextrose solution IACDI and of
heparin on pH of blood. Left hand column shows low pH of blood
from five rabbits In syringe which contained ACD as anticoagu-
lant. Right hand column shows normal pH In syringe which
contained heparin.

ACD Blood

Heparinized

Blood

No. 1

6.680

7.441

6.820

7.475

6.700

7.505

6.778

7.515

No. 2

6.005

7.339

6.240

7.342

6.156

7.364

6.159

7.404

No. 3

6.708

7.500

6.715

7.545

6.791

7.465

6.725

7.421

No. 4

6.806

7.390

6.775

7.375

6.830

7.475

6.755

7.434

No. 5

6.690

7.510

6.700

7.491

6.790

7.542

6.756

7.585

-o Heparihi2ed Blood
-• ACD Blood

Chart 1. — Changes in blood pressure (B.P. ), standard
bicarbonate (S.B.), Pco2 and pH of the arterial blood
when uniformly hyperventilated animals are bled and
then transfused with citrated or heparinized hlood.
(Values are averages.)

Explanation of numbers under hlood volume: (1) Be-
fore removal of blood, (2) immediately after blood
removed, (3) five minutes after blood removed, (4)
immediately after hlood transfusion, (5) three minutes
after hlood transfusion.

VOL. 97, NO. 1 • JULY 1962

BEFORE BLOOD
REMOVED

IM M EDIATELY AFTER
BLOOD REMOVED

IM M EDIATELY AFTER
BLOOD TRANSFUSION

30 MIN. AFTER
BLOOD TRANSFUSION

GROUP 1

RAPID ACD BLOOD
TRANSFUSIONS
HYPERVENTILATION
WITH ROOM AIR

—

TRANSFUSION
^

GROUP II

RAPID HEPARINIZED
BLOOD

TRANSFUSIONS
HYPERVENTILATION
WITH ROOM AIR

—a

TRANSFUSION

can

Chart 2. — Read each tracing right to left. Changes in end-expired carbon dioxide concentrations. The lower
the amplitude, the lower the end-expired carbon dioxide. Removal of blood lowers end-expired carbon dioxide due
to decreased cardiac output.1415

C02 increased (Chart 2) in association with the
pronounced rise in Pco2 and leveled off in less
than three minutes, the change coinciding with the
drop in Pco2 and increase in pH.

Group II. Rapid heparinized blood transfusions ;
hyperventilation with room air.

Five rabbits with an average weight of 2.69 kg.
(5.9 lb.) were used. The procedure was that essen-
tially followed in Group I.

Soon after bleeding, there was only a slight
increase in arterial Pco2. Administration of hepar-
inized blood produced only a slight decline in pH,
a slight increase in Pco2 from 36 mm. Hg. to 49
mm. Hg. and a slight decrease in standard bicar-
bonate (Chart 1) .

Bleeding caused a fall in end-expired carbon
dioxide due to decreased pulmonary blood flow14,15
(Chart 2). Transfusion with either citrated or
heparinized blood caused an immediate rise in end-
expired C02. In Group I, acd blood gave a rise in
end-expired C02, presumably because of increased
excretion of C02 into the lungs and increased pul-
monary blood flow. In Group II, the rise in end-
expired C02 was probably largely due to increased
pulmonary blood flow. Thirty minutes following
transfusion with citrated or heparinized blood, the
end-expired C02 had returned to normal.

Group III. Rapid ACD blood transfusions ; spon-
taneous unassisted respiration.

Five rabbits with an average weight of 2.36 kg.
(5.2 lb.) were studied. Throughout the procedure,
respirations were spontaneous and unassisted.
Changes in rate and depth were closely observed
and related to acid base changes. Chart 3 shows
changes in the average respiratory rate, blood pres-
sure, standard bicarbonate, Pco2 and pH.

0 0 Heparinized Blood

• ACD Blood

B. P. 100

mmHg

S. B. 30 .

Pco2 80

mmHg

(1) (2) (3) (4) (5) 10 20 30 40 Min.

Chart 3. — Changes in blood pressure, standard bicarbo-
nate, Pco2 and pH of arterial blood when spontaneously
breathing animals are bled and then transfused with
citrated or heparinized blood.

Explanation of numbers under blood volume: (1)

Before removal of blood, (2) immediately after blood
removed, (3) five minutes after blood removed, (4) im-
mediately after blood transfusion, (5) three minutes
after blood transfusion.

Before bleeding, the respiratory rate was slightly
less than normal values given for rabbits, probably
because of the barbiturate depression. The Pco2
and standard bicarbonate were also slightly below

CALIFORNIA MEDICINE

normal. However, pH (7.46) was normal. These
animals had a mild compensated metabolic acidosis
due to dehydration and starvation.

Bleeding was followed by an increase in the re-
spiratory rate. The end-expired C02 concentration
was diminished, probaby resulting from a combina-
tion of hyperventilation and diminished circulating
blood volume. A slight further decrease in Pco2
was noted, and a pH shift to the alkaline side (7.56)
followed.

Immediately after transfusion, the respiratory rate
was twice the pretransfusion rate, the pH dropped
to 7.12, and the Pco2 increased to 70 mm. Hg. The
end-expired C02 concentration was low, because
of compensatory hyperventilation.

After three minutes, the respiratory rate was
greatly diminished and the acid-base balance was
similar to that before transfusion. Compensation was
attained in a very short period, seemingly through
respiratory mechanisms which were not dangerously
obtunded by deep anesthesia.

Acid-base equilibrium was maintained for 20 to
30 minutes very close to that immediately following
transfusion. The pH was slightly lower and the Pco2
slightly higher than before ACD transfusion.

Group IV. Rapid heparinized blood transfusions;
spontaneous unassisted respiration.

Five rabbits with an average weight of 2.5 kg.
(5.5 lb.) were studied. As in Group III. respirations
were spontaneous and unassisted.

The acid-base balance (Chart 3) before bleeding
was well within normal limits.

Bleeding induced changes (Chart 3) in blood
pressure. pH, Pco2 and standard bicarbonate simi-
lar to those in the previous groups — hypotension,
hyperventilation and slight respiratory alkalosis.
Within five minutes of hypotension, compensatory
changes had begun.

When blood volume was restored with heparinized
blood in a rabbit breathing spontaneously (Chart
3) there was a similar rise in blood pressure and
considerably less depression of pH and less eleva-
tion of Pco2 than occurred after transfusion with
citrated blood. Thus , during transfusion with
heparinized blood, spontaneous respiration in the
anesthetized rabbit can maintain pH of the blood
within normal range.

DISCUSSION

Acid-citrate-dextrose (acd) solution used as an
anticoagulant and a preservative is an extremely
acid solution with a pH of 4.85 to 5.0. 7,13 Whole
blood drawn in citrate solution has a pH range of
6.4 to 6.9. This acidity may be attributed to the citric

VOL. 97, NO. 1 • JULY 1962

• — ---• ACD Blood

Chart 4. — Stored ACD blood shows severe fall in pH,
rise in Pco2 and loss of standard bicarbonate during
first day following collection. Stored heparinized blood
shows a gradual increase in acidity over 13 days.

acid-sodium citrate plus increasing amounts of
lactic acid from the breakdown of dextrose.

Previous reports as to the diminished pH and
increased Pco2 of stored citrated blood have been
confirmed in our laboratory1,7 (Chart 4).

In transfusions of 500 to 1,000 ml. in an adult
whose renal and respiratory compensatory mechan-
isms are intact, changes in the acid-base balance
may not be apparent. In an infant whose blood
volume may easily be replaced once or twice (as in
exchanged transfusions or major operations with
severe blood loss) or in an adult undergoing exten-
sive surgical treatment and requiring replacement
of a large amount of blood, deranged acid-base
balance may be obvious and clinically important.

Chart 5 shows the respiratory rate, venous pH,
P C02, and standard bicarbonate of a six-hour-old
newborn subjected to an exchange transfusion using
citrated blood approximately a week old, with pH
6.55, Pco2 more than 200 mm. Hg. and standard
bicarbonate below 6 mEq. per liter. Determinations
were made from umbilical vein samples obtained
before, during and immediately after exchange trans-
fusion. A peripheral venous sample was checked one
hour after the procedure. As in the animal experi-
ments, there was an increase in Pco2, decrease in
pH, and minimal, if any, decrease in standard

EXCHANGE

S. B.

mEq/L

Chart 5. — Blood chemistry during exchange hlood transfusion in newborn with ACD blood. S.B. — Standard bicarbonate.

bicarbonate during the period of exchange trans-
fusion. An over-all increase in respiratory rate
was also noted during the procedure, increasing
with each individual injection of blood. All deter-
minants except respiratory rate returned to pretrans-
fusion levels gradually during the next hour.

As a volatile acid, carbon dioxide is eliminated
through the lungs. A slight to moderate increase in
the C02 and decrease in pH of the blood stimulates
the respiratory center, this being manifested as an
increase in rate and depth of respiration until the
excess carbon dioxide is blown off. This mechanism
probably accounts for the increase in respiratory
rate observed in the group of rabbits that received
citrated blood and in the neonate given an exchange
transfusion.

The pH of heparinized blood was shown to be
within normal limits and storage altered the pH
much less than it did in citrated blood (Chart 4).
Hyperventilated rabbits that received heparinized
blood transfusions did not show decided changes in
pH and Pco2, whereas hyperventilated rabbits that
received citrated blood transfusions showed a drop
in pH and elevation of Pco2.

Thus, aggravating effects can be foreseen in a

patient with pre-existing acidosis who receives trans-
fusions of citrated blood. Respiratory acidosis may
be heightened if hypoventilation persists or if C02
diffusion is impaired. Metabolic acidosis may be
worsened if the alkali reserve is severely depleted
or exhausted. The effect of increased acidity (low
pH) and increased Pco2 on the myocardium must
also be considered. Previous reports by other in-
vestigators10 and results in our laboratory indicate
that myocardial contractile force may be dimin-
ished, an effect which may help explain the in-
creased morbidity and mortality rates following
transfusions of citrated blood.

Division of Anesthesiology, Children’s Hospital of Los Angeles,
4614 Sunset Boulevard, Los Angeles 27 (Leigh).

REFERENCES

1. Abbott, J. P., Ragland, J. B., De Bakey, M. E., and
Cooley, D. A.: Observations on blood drawn and stored for
open heart surgery; a study of 10 anti-coagulant solutions,
A. J. Clinical Pathology, 33:124-134, Feb. 1960.

2. Andersen, O. S., and Engel, K. : A new acid-base
nomogram; an improved method for the calculation of the
relevant acid-base data, Scandinavian J. Clin. Lab. Invest.,
8:33, 1956.

3. Astrup, P., Jorgensen, K., Lizzard Andersen, 0., and
Engel, K. : The acid-base metabolism; a new approach,
Lancet, 1 (7133) :1035-1039, 1960.

CALIFORNIA MEDICINE

4. Bentley, H. P., Ziegler, N. R., and Krivit, W.: The
use of heparinized blood for exchange transfusion in infants,
A.M.A. J. Dis. Children, 99:24-33, Jan. 1960.

5. Collier, C. C., Affeldt, J. E., and Andrew, F. F. :
Continuous rapid infrared CCL analysis (fractional sampling
and accuracy in determining alveolar CO:), J. Lab. and
Clin. Med., 526, April 1955.

6. Farquhar, J. W., and Smith, H.: Clinical and bio-
chemical changes during exchange transfusion. Arch. Dis.
Childhood, 33:142, April 1958.

7. Graham, B. D., and Heyn, R. M. : Acid-base homeostasis
during exchange transfusion of newborn infants with pre-
served blood, Pediatrics, 15:241-247, 1955.

8. Handbook of Circulation, Saunders, 1959.

9. Handbook of Respiration, Saunders, 1958.

10. Hopkins, A. L., Anzola, J., and Clowes, G. H. A.:
Quantitative experimental comparison of effect of severe
hypercapnia on brain and heart, Surgical Forum, 5:736,
1954.

11. Howland, W. : Cardiovascular and clotting disturb-
ances during massive blood replacement, Anesthesiology,
19:140-151, 1958.

12. Howland, W., Scheweizer, 0., Boyann, P., and Dotto,
A.: Physiologic alterations with massive blood replacement,
S.G.O., 101:478, 1955.

13. James, L. S. : Physiology of respiration in newborn
infants and in the respiratory distress syndrome, Pediatrics,
24:1069, Dec. 1959.

14. Leigh, M. D., Jones, J. C., and Motley, H. L. : The
expired carbon dioxide as a continuous guide of pulmonary
and circulatory systems during anesthesis and surgery, J.
Thoracic and Cardiovascular Surg., 41:597-610, May 1961.

15. Leigh, M. Digby, Jenkins, L. C., Belton, M., and
Lewis, Jr., G. B.; Continuous alveolar carbon dioxide
analyses as a monitor of pulmonary blood flow, Anesthesi-
ology, 18:878, 1957.

16. Leroux, M. P. : One hundred and four transfusions in
newborn with the aid of heparinized blood, Presse Med.,
68:435-437, March 5, 1960.

17. Lizzard Andersen, O., Engel, F., Jorgensen, K., and
Astrup, P. : A micro method for determination of pH, carbon
dioxide tension, base excess and standard bicarbonate in
capillary blood, Scandinav. J. Clin. & Lab. Invest., 12, 177,
1960.

18. Miller, G., McCoord, A. B., Joos, H. A., and Clauser,
S. W.: Serum electrolyte changes during exchange trans-
fusion, Pediatrics, 13:412, 1954.

19. Pew, W. L. : Exchange transfusion using heparinized
blood, J. Pediatrics, 49:570, Nov. 1956.

20. Valentine, G. H.: Heparinized blood for exchange
transfusion, Lancet, 2:21, July 6, 1958.

Care of the Umbilical Cord in the Newborn

A Program to Reduce Infection and Promote Healing

JOHN B. SARRACINO, Lieutenant Colonel, M.C.,

PATRICIA A. RYAN, Major, A.N.C., and ELLEN MASTROIANNI, Major, A.N.C.,
U. S. Army Hospital, Fort Ord

Attention was focused on care of the umbilical
stump of newborn infants at U. S. Army Hospital,
Fort Ord, when we noticed that mothers were re-
peatedly calling for advice with regard to infection
at that site. How to reduce the incidence of in-
fection became our concern.

Since the nursery for some time had been free
of clinical infection, mainly impetigo and diarrhea,
no additional bacteriological study was made of
the environment or of contamination control there.
No change was made in the routine of a 3-minute
anteroom scrub, an admission bath with hexachloro-
phene for the newborn, use of an iodophor solu-
tion2,3 in dip basins for personnel handling babies,
use of the same solution for cleaning floors, walls
and equipment, spacing of cribs, sterilization of
nursery linen, cultures of the formula, room air and
equipment, and culturing of the nose, throat and
hands of personnel for pathogenic organisms. Any-
one having a culture positive for Staphylococcus
aureus was excluded from the nursery and, in some
instances, from the obstetrical service also. Per-
sonnel were closely observed and were conscien-
tious in maintaining technique.

When attention was directed to umbilical cord
stumps in the nursery, it became evident that in
most cases they were too long. In almost all cases
the stump drooped over onto the abdominal skin,
the lower side of the cord remaining moist and
warm while only the upper side was exposed for
drying. In addition, the cord was covered by the
baby’s diaper and shirt; often the baby was lying
prone. Figure 1 shows a severed cord of extra-
ordinary length. The usual length of the cord stump
when the baby came from the delivery room was
1 to 1 !/2 inches, as shown in Figure 2. After atten-
tion was turned to the problem, if a cord was too
long, a clamp was applied next to the abdominal
wall and the cord was clipped with sharp scissors
to 14 inch above the clamp. When the cord is cut
the right length, it tends to “mushroom” over the
clamp. Lest the cord be cut too close to the clamp,
the infant’s legs and lower body should be held

Submitted February 21, 1962.

• Problems related to infection, slow-healing and
continued moisture of the umbilical cord stump
were considerably reduced at an Army Hospital
nursery by a program of meticulous care that
included shortening the stump, exposure to air
(sometimes with added heat) and application
of povidone-iodine solution.

Figure 1. — An unusually long cord that was shortened
to about inch above the clamp.

. ...

Figure 2. — General appearance and length of cord when
baby arrives from the delivery room.

CALIFORNIA MEDICINE

firmly. On several occasions before this precaution
became routine, the kicking or turning of the infant
caused the cord to be cut so short that the clamp
did not hold and suturing was necessary to stop
bleeding.

After the reclamping and trimming of the cord,
the umbilical area was left exposed for about six
hours to permit faster drying and observation for
bleeding. In addition a solution of povidone-
iodine1,4 was applied to the stump every 12 hours.
If the cord appeared not to be drying rapidly
enough during the nursery period, an electric light
bulb was turned on to supply additional heat. Figure
3 shows a cord stump at 24 hours, the time the clamp
is usually removed.

With this method of care the cord looked cleaner
and healed faster (see Figure 4). In some cases
the cord “fell” off before the infant was discharged
home on the fifth day of life, causing an occasional
inquiry from a mother as to whether the cord
should be “off so soon.”

Approximately 1.800 newborn babies were cared
for in the nursery in a period of a year following
the institution of the program of umbilical cord
management described. Telephone calls from anx-
ious mothers and home and clinic visits related to
a slow-healing umbilicus were reduced by 90 per
cent.

This material has been reviewed by the Office of The Sur-
geon General, Department of the Army, and there is no
objection to its presentation and/or publication. This re-
view does not imply any endorsement of the opinions ad-
vanced or any recommendation of such products as may
be named.

Office of the Chief, Pediatric Section, U. S. Army Hospital, Fort
Ord (Sarracino).

REFERENCES

1. American Medical Association Council on Drugs: New
and Non-Official Drugs — 1961. J. B. Lippincott Company,
Philadelphia, 1962. Povidone iodine, pp. 186-187.

Figure 3. — Cord 24 hours old — short, dry and firm.
Clamp is next to abdominal wall. Discolored area is ap-
plication of iodine solution.

Figure 4. — Left, cord on fourth day of life; Right, cord
on fifth day of life (day of discharge from hospital).

2. Bogash, R. C.: A new iodophor disinfectant: Survey
and evaluation, Bull. Am. Soc. Hosp. Pharmacists, 12:135-
136, March-April 1955.

3. Johns, C. K.: Iodophors as sanitizing agents, Canadian
J. Technology, 32:71-77, 1954.

4. Nungester, W. J., and Kempf, A. J.: An infection —
Prevention test for the evaluation of skin disinfectants, J.
Infect. Dis., 71:174-178, Sept.-Oct. 1942.

A Role for the Physician in Civil Defense

MAX L. LICHTER, M.D., Melvindale, Michigan

In our thermonuclear age, the danger is ever
present that this energy could be used to destroy us
and all mankind. Logical thinking might lead one
to believe this will never happen because there
could be no victor, only victims in every land. Un-
fortunately, this passive view oversimplifies a prob-
lem which is fraught with complexities. We must
be realistic and accept the possibility of mass attack
upon our country.

An aggressor must be made to understand that
our military and scientific capabilities match, and
even exceed his. He must also comprehend that the
will and determination of the American people is
firm, a potent force which is an integral part of our
total national defense posture. He must know how
deeply we value our way of life, the respect we hold
for the individual and for law and order, and the
passionate regard we have for freedom. He must
realize that we are prepared to defend these beliefs
to the bitter end.

To accomplish this preservation, our nation must
survive — not as individuals, but as a population
which can carry on our cherished ideals. We, as
civilians, have the same responsibility to defend
our country as those of our nation who are in the
Armed Forces. Thus, we have civil defense, whose
basic objective is national survival. To fulfill this
objective, preparation and planning have to be
carried out. This requires the active participation
of all of this country’s citizens to the utmost of their
abilities.

For a nation to rebuild itself after a holocaust,
there must be people whose health has been main-
tained at as high a standard as possible. Following
attack, there will be a huge number of injured
people who must be treated so that they may join
their fellows in the rehabilitation effort which
follows. During the post-attack and recovery phase,
environmental conditions will be so disrupted that
many illnesses can be expected. These will need to
be treated and cared for if the health of our sur-
viving population is to be maintained. The com-
plexities of the medical care problem will be
enormous but not insurmountable.

Presented at the Annual Meeting of the United States Civil Defense
Council, October 17, 1961, Los Angeles. Dr. Lichter is chairman of
the Committee on Disaster Medical Care of the American Medical
Association.

Submitted December 27, 1961.

• Recognition of the possibility of nuclear at-
tack upon the U. S. imposes on the American
physician the obligation of preparing to deal
with its consequences. The responsibility has
been accepted but every physician must con-
tinue his effort to increase our medical capa-
bilities.

Organization and planning at all levels must
continue and it is most essential that physi-
cians participate in the education of the public.
The A.M.A. through its Committee on Disaster
Medical Care has played an active role in the
development of civilian training courses and
medical planning for disaster in this country.

Medical care is a most crucial need in the restora-
tion of our country. With it planned for carefully
and intelligently, the American people will know
that medical care will be available in a time of dis-
aster. Thus, a most important morale factor can be
provided which will assure our citizens and give
them a feeling of hope that they will desperately
need. This can be supplied only by the physician
and his aides.

The people of the United States have always
looked to their physicians for care and comfort in
time of illness or injury. It is to the physician, then,
that the American people will look in time of mass
disaster. The physician, who is the leader of the
medical care team which utilizes the important com-
petence of the allied health professions, will accept
the responsibilities that the American people expect
him to assume.

Already, physicians have been actively engaged
in civil defense throughout the country at the city,
county, state and national levels. Planning and
organizing has gone forward to a laudable degree.
The American Medical Association, through its
Committee on Disaster Medical Care, has given
stimulus and encouragement to the many medical
societies throughout the country, and has offered
guidance and assistance in the development of
planning.

Perhaps the most significant accomplishment of
the Association is its “Report on National Emer-
gency Medical Care.” This was prepared at the
request of and for the Office of Civil and Defense
Mobilization. I strongly urge each of you to obtain
a copy of the summary of the report and study it.
Herein is outlined the role and responsibility of

CALIFORNIA MEDICINE

the medical profession, and therefore of the physi-
cian. Among these are the following:

Promote sound planning for mass casualties at all
levels of government and at all levels within the
professional medical and health organizations.

Encourage the population of the United States
to engage in individual and collective survival
training.

Lend assurance that a successful recovery from a
mass attack is possible.

Ensure adequate medical training of personnel
of the medical and health professions and of all
other personnel potentially able to assist themselves
and the health professions in the care and treatment
of the survivors in a mass attack.

The foregoing, a partial listing, represents the
responsibilities of the physician in the phase of
preparation and education for mass attack. Much
has been done but there is more that needs doing.
The carrying out of the role and responsibility of
the physician will require the continued effort of
the many physicians who have already devoted
themselves to the medical care aspects of civil
defense. The development of a medical care pro-
gram has to be a continuing process which requires
that increasing numbers of physicians engage them-
selves actively in this endeavor.

Every civil defense plan has its medical section.
However, implementation of this planning, in terms
of the development of organization, is the critical
need in most instances. In the overall civil defense
plan, at whatever level, health cannot be regarded
as just another technical service. Since the medical
aspects cut across almost all the survival actions,
it is recommended that the health branch of any
plan be given strong support by the technical
services in the plan. The health needs are so crucial
to our survival that they must be given top priority.
This will require the physician to be well aware of
the entire civil defense plan so that the medical por-
tion can function in the best possible manner. Also,
the medical people must know and understand the
concepts of the civil defense organization so the
health branch can be flexible in fitting into any
concepts as they may be developed.

Perhaps the physician’s greatest role at this stage
of civil defense development is to encourage the
people to take survival training courses and to
participate in these programs himself. In addition,
educational projects for physicians and members
of the allied health professions must be undertaken.
Any plan is worthless without people who have
been taught to understand it and know how to
operate it. It must be realized that not enough
physicians would be available in the postattack
phase to care for all the injured. And of course
there will be the usual needs for medical care of

persons with illnesses not related to the attack. The
planning, therefore, would contemplate that the
professional capabilities of the physician would be
utilized in those situations where only he can func-
tion. In this regard, one of the major functions
of the physician would be to act in a supervisory
capacity to the aides he has trained.

It is necessary to train people to assume some
of the lesser activities of physicians. This training
may be given to members of the allied health pro-
fessions whose present capabilities can be expanded
to enable them to perform additional services. This
preserves the physician’s time and skills for the
more serious and complicated cases.

It is also necessary to train nonprofessional peo-
ple to assist in the operation of medical care facili-
ties. Required would be instruction in basic first aid
in a course geared specifically to the civil defense
problem, and such advanced training as the needs
of planning might indicate. The services of such
volunteers are essential in the operation of the Civil
Defense Emergency Hospital (cdeh). After the
first-aid training specific instruction concerning the
CDEH would be carried out.

It is important that all of this training be con-
ducted by physicians in order that the trainees be
properly oriented.

The matter of survival training is of great con-
cern to the physician and he has to take an active
role in this area. Although special medical training
must be given to as many as possible, it should be
recognized that, initially, only a small proportion of
the population will volunteer for the kind of train-
ing needed. In the aftermath of an all-out nuclear
attack it is quite likely that survivors, injured or
uninjured, would be confined to fallout shelters for
two weeks or more, or until such time as the radia-
tion level fell to a point where it could be tolerated.
During this period, definitive treatment would be
unavailable. It would be up to the individual or to
his family and neighbors to provide the care needed
to make survival possible.

It is therefore imperative to the objective of
national survival (as well as individual survival)
that as many people in the United States as can
possibly be reached receive some training in help-
ing themselves and each other. To this end the
United States Public Health Service with the guid-
ance of the American Medical Association has de-
veloped a “Medical Self-Help” training course,
which will be offered to the American people.
Three workshops are to be conducted across the
country by the U. S. Public Health Service with
the co-sponsorship of the American Medical Associ-
ation to launch this program and to develop methods
for presenting the material to ever increasing num-
bers of people. As the program expands into each of

VOL. 97, NO. 1 • JULY 1962

the states, it will be under the guidance and spon-
sorship of the state medical association and the com-
ponent medical societies of the state association. The
conduct of the medical self-help course will be by
physicians, or under their supervision. This is an
ambitious program which with the cooperative effort
of all physicians can succeed as it must.

It is necessary for the physician himself to be-
come acquainted with the principles of mass casualty
care. Since conditions in the postattack period are
going to be austere, some degree of familiarity with
care under such circumstances is advisable. The
subject of triage, which is the sorting and classify-
ing of injured persons, needs to be considered. The
priority for treatment under mass casualty condi-
tions may differ from that used in current peace-
time practice. Radiation sickness is rarely seen in
ordinary circumstances but may be prevalent fol-
lowing attack, and the physician needs to famil-
iarize himself with the symptomatology related to
varying degrees of exposure, and must also learn
the principles of treatment. The physician needs to
know something about environmental and sanitation
problems, for they are usually of pressing impor-
tance following disaster.

All hospitals and medical staffs need to develop
plans for the utilization of their facilities in the
event of disaster of any magnitude. Not all hospi-
tals will be rendered inoperative, and those that
remain would have an incalculable contribution to
make. The training afforded the medical staff as
well as all members of the hospital team would be
of great value to the medical care effort.

The physician may be asked for advice by his pa-
tients and his friends or requested to give talks to
various groups. Much emphasis should be placed
upon the training and educational responsibilities
of the physician. From a medical standpoint, the
educational aspects of the program are the most
important at the moment, although this emphasis
on training and education cannot in any way be
construed to minimize the importance of the many
other responsibilities that physicians have in the
civil defense picture.

The American Medical Association long has been
interested in the problem of civil defense. It was
the first national health organization to appoint
a committee (in 1946) to look into this subject.
This committee has become the Council on National
Security. The Council now has, as part of its struc-
ture, a Committee on Disaster Medical Care which
has served in advisory capacity to the Federal Civil
Defense Administration, the Office of Civil and De-
fense Mobilization, and the United States Public
Health Service. Much attention has been given to
encouraging the state medical associations in their
consideration of civil defense. The Committee on

Disaster Medical Care has held regional meetings
in several parts of the country for the past four
years. It has now nearly completed its second round
of visiting the various regions in the United States
and has noted a commendable degree of progress
and increased attention to the problem by the vari-
ous state associations.

Each year just before the beginning of its annual
meeting in June, the association, through its council
and committee, sponsors a one-day meeting which
deals with civil defense from a national standpoint.
In addition, a two-day meeting called the County
Medical Societies Conference on Disaster Medical
Care, is held each November. The purpose of this
meeting is to focus on state and local civil defense
planning and to provide a forum where physicians
involved in this effort can obtain advice and guid-
ance. Further, the council, through its commendable
staff, has developed a bibliography of all available
films dealing with the medical care aspects of civil
defense and a bibliography of publications and
manuals. The association maintains a complete
library of this material.

A newsletter called the Civil Defense Review is
published bi-monthly by the council, which presents
current information on medical civil defense activi-
ties throughout the country.

To translate all the effort of the medical profes-
sion and of individual members into effective action
requires the closest relationship with civil de-
fense authorities throughout the country. Civil
defense directors should solicit and encourage the
interest and participation of physicians. In turn,
medical societies and physicians should offer their
services and abilities to the civil defense organiza-
tions. This needs to be a cooperative effort and
should be furthered in every city and county.

As has been true so often in the past, the Ameri-
can physician stands ready to care for his fellow
man. This has always been done on a voluntary
basis, the cornerstone of a philosophy which has
provided the American people with the finest medi-
cal care available anywhere. This has been accom-
plished without external pressures because of the
ingrained sense of responsibility which is a part
of the credo of the physician. The medical care
aspect of civil defense will be conducted by the
American physician in the same time-honored vol-
untary manner. In many places in this country the
first community civil defense effort was initiated
by physicians which stimulated the formation of
the local civil defense effort. Physicians cherish their
traditions and precepts, and will continue to live
by them. Civil defense, as a new discipline in Ameri-
can life, will be supported by physicians recognizing
the crucial need for medical care.

2900 Oakwood Boulevard, Melvindale, Michigan.

CALIFORNIA MEDICINE

MEDICAL MISCELLANY

Help for Male IMocturics

A Flexible, Reversible Urinal

WILSON STEGEMAN, M.D., Santa Rosa

In reply to a 1959 questionnaire, 288 urologists
estimated that 54 per cent of men over 50 years of
age get up at least once a night to urinate. This
was estimated to increase to 64 per cent by age 65.
When at home, many of these night-voiders manage
by one device or another to circumvent the ob-
jectionable, disturbing trip to the bathroom. How-
ever, when traveling, visiting or sleeping in strange
surroundings, their discomfiture frequently becomes
so real that many of them prefer to remain at home
rather than risk embarrassment.

The depicted urinal, conceived and designed to
assist this large group of men with their problem,
consists of a flexible, smooth, reversible latex bag
of 14/2 quart capacity. It is equipped with an
elongated neck and a positive-sealing roll-down
closure apparatus. Silent, safe, easy closure can
readily be accomplished under the bed clothes,
without the need for turning on a light. The bag
can then be safely deposited on the floor without
danger of leakage or spilling.

In the morning, after safe and inconspicuous

transport to the bathroom in a dressing-robe pocket,
the bag can be rinsed and hung up to dry. It is
designed to hang open, and having no crevices or
acute folds, it drains and dries quickly. If it is to
be packed immediately, the bag is flipped inside-out
and either hung up to dry by the inside hanging
loop or dried with a towel. It functions equally
well in this reversed position. A minimum of cleans-
ing effort is needed to keep the bag fresh. For
packing, it folds compactly. The flexible urinal also
can be useful to crippled persons, paraplegics and
hunters and campers; it can be used safely in a
sleeping-bag. Flyers of small planes have found it
better than some of the various “relief tube” con-
trivances, especially the feature of inconspicuous
disposability on deplaning.

Although the bag is valveless and not intended
for wearing, holes in the winding rod permit
securing it to the body by a band around the waist,
for use by immobile or comatose bed patients.

Submitted December 4, 1961.

1166 Montgomery Drive, Santa Rosa.

Urinal bag (a) open and ready for use, (b) filled and sealed by winding the neck around winding stick and fast-
ening with rubber ring, (c) being reversed for cleansing and drying, (d) folded compactly for packing.

VOL. 97. NO. 1 • JULY 1962

Mechanical Aids at the Operating Table

RICHARD C. THOMPSON, M.D., San Mateo, and
WILLIAM B. NEFF, M.D., Redwood City

A multipurpose apparatus to make a number of
procedures at the operating table easier to do and
often with less assistance has been devised. It can be
used for abdominal retraction, especially for gall-
bladder surgery, for a suspension laryngoscope, for
mouth prop support during tonsillectomy, for chin
support to ensure a patent airway during general
anesthesia in the operating room and in the dental
office, and for supporting a Mayo tray.

Abdominal Retractor

Adequate exposure of the gallbladder frequently
requires a second assistant, which may add con-
siderably to the cost to the patient. Retracting the
ribs and liver to provide good exposure can be
difficult and very tedious and may keep a highly
trained man from more productive and creative
effort. It can be done better by means of a mechani-
cal retractor (Figure 1) to be described.

The component parts are a metal rod, Figure 2, B,
a half inch in diameter, bent at right angles, which
can be attached to the rail of the operating table
with a simple clamp, Figure 2, L, O. The clamp
may slide the length of the table so as to be used
over any part of the body. The horizontal portion of
the rod projects over the chest of the patient and
is adjusted to the optimal height and position. On
the horizontal portion are placed one or more uni-
versal screw clamps (Figure 2, K, M ) , which hold in
position retractors, such as a Richardson retractor
or a Crile blade (Figure 2, C, D, E, F, and G) . In
Figure 1, A, the Richardson retractor holds the
costal margin back and the Crile blade (Figure
1, B ) then is used to gently retract the liver. The
great versatility of this system for retraction permits
the blades to be inserted in any position in the
wound and at any desired angle. It is not in the
surgeon’s way as much as an assistant might be,
and it can be put in place for use in thirty to sixty
seconds. This retractor has been used extensively for
about one year by a number of different surgeons at
Mills Memorial Hospital, Peninsula Hospital and
Sequoia Hospital, San Mateo County, California.

Suspension Laryngoscope

The laryngologist needs both hands to operate
skillfully on the vocal cords, one to use the suction

Submitted December 11, 1961-

Figure 1. — New abdominal retractor especially valuable
during cholecystectomy. (A) Richardson type blade re-
tracting the superior margin of the wound and ribs. (B)
A Crile blade retracting the liver and hi'lum.

' ... . ■

Figure 2. — Component parts of the Thompson support-
ing and retracting apparatus.

tube, the other for the operating instrument. The
strain of sustaining exposure of the cords, during
polypectomy, for instance, may be enormous unless
a suspension laryngoscope is used.

A special clamp to hold the Foregger laryngoscope
(Figure 2, H), or other laryngoscopes that are
available (Figure 2, N) has been devised. To it is

CALIFORNIA MEDICINE

Figure 3. — A new suspension laryngoscope. With this
attachment any available laryngoscope can be used as a
suspension laryngoscope. Freedom of motion is main-
tained while the scope is being inserted.

attached a steel bar which slides into the universal
joint of the suspension mechanism already de-
scribed. An amazing freedom of motion of the
laryngoscope is provided. The laryngoscope can be
inserted into the patient’s mouth, the cords exposed,
and the exposure sustained simply by tightening the
two screw clamps (Figure 3). As with other cur-
rently marketed suspension laryngoscopes, patients
must be kept relaxed and quiet when the laryngeal
exposure is maintained for a long period with a
fixed and rigid device. When respiration is aug-
mented by a ventilator of the cuirass type, deep
relaxation can be provided and more prolonged pro-
cedures can be done safely.

Mouth Prop Support

During a tonsillectomy the surgeon and the anes-
thesiologist cooperate to provide exposure of the
operative site and a continuously patent airway.
When a Davis or Mclvor mouth prop is used, it is
usually supported by the anesthetist (a tedious and
tiring task) or by the Mayo stand, which is difficult
and clumsy to adjust. Or it may even be propped by

Figure 4. — Mouth prop hook. Davis or Mclvor mouth
props can he supported in the optimum position to pro-
vide a patent airway and exposure of the operative site
with the mouth prop hook. It can be readjusted in sec-
onds to meet varying needs.

Figure 5. — The Thompson chin support. A silicone rub-
ber sphere on the end of a ^-inch rod fits between the
rami of the mandible to maintain extension of the head
and elevation of the chin during general anesthesia. The
objective is a patent airway.

an instrument resting on the patient’s chest, which
restricts respiration.

The Thompson mouth prop support (Figure 2,1),
is another attachment which consists of a simple
steel bar with a hook on the end. This attachment
is placed in the universal screw clamp. After the

VOL. 97, NO. 1 • JULY 1962

Figure 6. — The chin support as used in a dental office
provides stability of the operative field and relieves the
anesthetist of the chore of holding the chin.

surgeon fixes the mouth prop in optimal position,
the anesthetist adjusts the hook and secures the
clamp to support the mouth prop (Figure 4), which
then is stable. This frees the anesthetist’s hand to
make necessary adjustments of other equipment.

Chin Support

The Thompson chin support is a curved rod with
a silicone rubber sphere 1 inch in diameter on one
end (Figure 2, /). The rod fits into the previously
described universal joint, and permits the applica-
tion of pressure to the chin as gently or as firmly as
necessary in any direction. The simplest way to
maintain the airway is for the anesthetist to support
the patient’s chin with his hand, but this is tiring

and prevents his attending to other procedures with-
out risk of relaxing the support enough to impair
the airway. Some anesthesiologists use intubation
simply because chin-holding becomes too fatiguing.
Now a handy and simple apparatus for mechani-
cally supporting the chin can be carried as routine
equipment on any anesthesia machine, and it can be
attached quickly to the operating table to provide
chin support whenever needed (Figure 5). If it is
possible to obtain a clear airway by extension of
the head and support of the chin, this device will
maintain the position.

Oral surgeons find the chin support helpful, for
it not only assists in providing a continuously patent
airway but, by limiting the mobility of the chin
and head, makes operation easier. In addition, with
the chin support the anesthetist’s hand, which might
otherwise have to be used to support the chin, need
not be in the way.

Since continuous pressure such as is applied by
mechanical apparatus of this type may do some
harm, it is recommended that occasional adjust-
ments be made to change the pressure points, just
as a face mask is moved from time to time to
prevent injury to the nose or cheek. Also to be
borne in mind is that once the apparatus has been
adjusted in position, it is unwise to flex or extend
the table without first releasing the universal screw
clamp.

Mayo Stand

During ophthalmological operations under gen-
eral anesthesia a Mayo stand of a new type can be
used to hold the drapes away from the body, thus
giving the anesthesiologists ready access to endo-
tracheal equipment there. After the patient is in-
tubated, the Mayo stand is placed over the patient’s
chest and secured in place by means of the side rail
clamp (Figure 2, L, O) . Sterile drapes are then
placed over the top, leaving the field below readily
accessible. Adjustments in the height of the table
can be carried out without changes in adjustment
of the Mayo stand.

545 Fairfax Avenue, San Mateo (Thompson).

CALIFORNIA MEDICINE

CASE REPORTS

Recurrent Tetanus

HARVEY D. CAIN, M.D.. Vallejo, and

FRANK G. FALCO, M.D., Pacific Palisades

Tetanus is a relatively uncommon disease, the inci-
dence in California ranging from 0.3 to 0.4 per
100, 000. 8 Approximately half of the patients die
and most survivors are actively immunized with
toxoid. The number of persons who have a second,
separate attack of tetanus is therefore extremely
small. Only three cases of recurrent tetanus have
been reported in the American literature.5,1112 The
present case is the fourth.

In a review by Vener and Bower,12 six cases of
recurrent tetanus are discussed, and the importance
of distinguishing relapse of a first infection and
a second separate attack of tetanus is stressed. In
their opinion, if signs of tetanus return after the
patient has been completely asymptomatic for a
period of one month, then a new and separate in-
fection is assumed to have taken place. On the other
hand, Mobius7 said that relapse of an infection may
occur even after several years, the tetanus organism
having remained dormant while surrounded by cica-
tricial tissue and infection recurring upon rupture
of this protective cicatricial shell, perhaps by trauma.

REPORT OF A CASE

The patient, a 38-year-old Caucasian woman, was
admitted to the Communicable Disease Unit of the
Los Angeles County General Hospital October 31,
1953. For the three preceding days there had been
progressive symptoms of “fullness in the throat,”
difficulty in opening the mouth, difficulty in swal-
lowing, malaise and restlessness. At time of admis-
sion the patient could barely swallow liquids. Five
weeks before admission, the patient had had the left
upper molar extracted, and a week later had had a
granulomatous growth removed from the right mid-
dle turbinate of the nose. As far as was known, no
tetanus toxoid injections had been given.

Upon physical examination, dehydration, mod-
erate trismus and nuchal rigidity were observed. The
blood pressure was 120/70 mm. of mercury, the

From the Los Angeles County General Hospital, Communicable
Disease Unit, Los Angeles.

Submitted March 8, 1962.

pulse rate 100 per minute and the temperature was
100° F. No site of infection or foreign body was
found. The area from which the tooth had been re-
moved was well healed. Dental x-ray films were not
taken. Upon examination of the right turbinate, a
consultant in otolaryngology noted normal-appear-
ing granulation tissue. No evidence of pelvic infec-
tion or abortion was observed, nor was there any
sign of drug addiction. The muscles of the back and
abdomen were in spasm and the deep tendon reflexes
were hyperactive. Since the focus of infection could
not be identified, no cultures were obtained.

Hemoglobin was 15 gm. per 100 cc. of blood and
leukocytes numbered 8,600 per cu. mm. with 85 per
cent polymorphonuclear cells. The specific gravity
of the urine was 1.030. the reaction for albumin
three plus and for carbohydrate one plus; and upon
microscopic examination moderate amounts of bac-
teria were noted. (Later, following hydration of the
patient, results of urinalysis were within normal
limits.) On the date of admission, results of chemi-
cal analysis of the blood were as follows: Nonpro-
tein nitrogen 48 mg. per 100 cc., carbon dioxide 24
mEq., potassium 4.7 mEq., sodium 143 mEq. and
chlorides 105 mEq.

After intracutaneous and intravenous testing for
sensitivity with negative results, 120,000 units of
tetanus antitoxin was administered intramuscularly
and 40,000 units intravenously. Thereafter 1,500
units was injected every four days. Chloral hydrate
was given rectally or orally, in amounts of 0.9 to 1.2
gm. every two to four hours, as needed. Six hundred
thousand units of penicillin was injected intramus-
cularly every six hours. For the first eleven days
fluid intake was predominantly by vein. Tracheot-
omy was not required.

During the first ten days the patient had as many
as 20 to 30 generalized contractions a day, which
ranged from mild to moderately severe. On the ninth
hospital day tachycardia (110 to 140 beats per
minute) developed, and then persisted for seven
days. No generalized tetanic contractions occurred
after November 18 although mild spasms of the neck
and abdominal muscles lasted another six days.
X-ray films of the lumbar vertebrae on November
27 showed fractures of the left fourth and fifth
transverse processes without displacement. Before
she was discharged the patient received one dose of

VOL. 97, NO. 1 • JULY 1962

tetanus toxoid and was advised to complete a series
of three injections. On December 1 she was dis-
charged from the hospital as clinically cured of
tetanus.

Comment

The tachycardia that developed on the ninth day
after administration of tetanus antitoxin and per-
sisted for a week could have been a manifestation
of serum sickness. With regard to the x-ray evi-
dence of vertebral compression fracture, this has
been noted in as many as 20 per cent of patients
who survive tetanus.

Second Admission

Six and a half years later, on May 5, 1960, this
same patient was again admitted to the Communi-
cable Disease Unit with trismus, dysphagia and
nuchal rigidity. Symptoms had begun two days
earlier, with dysphagia. The next day a “drawing
sensation” began in the face and neck, and on the
day of admission the patient was unable to swallow
water. The only recent known trauma was a cut on
the left hand a week before admission. The patient
said she had had no injection of tetanus toxoid
other than that given in the hospital.

When examined she was observed to be in dis-
tress with painful trismus, risus sardonicus and
paraspinal muscle spasm. The blood pressure was
120/70 mm. of mercury, the pulse 100 per minute
and the temperature was 99° F. A gag reflex was
elicited and was followed by generalized tetanic
contractions lasting 90 seconds. The heart tones
were normal and no murmur or evidence of car-
diomegaly was noted. All deep tendon reflexes were
hyperactive Superficial lacerations on the middle
and index fingers as well as a small splinter in the
middle finger were found on the left hand.

The hemoglobin content was 13.0 gm. per 100 cc.
of blood. Leukocytes numbered 5,750 per cu. mm.,
with 70 per cent polymorphonuclear cells. Results
of urinalysis were within normal limits. On May 9
the blood urea nitrogen was 14 mg. per 100 cc., car-
bon dioxide was 20 mEq., potassium 4.2 mEq.,
chlorides 102 mEq., sodium 133 mEq., Ca 10.8 mg.
and Br 14.9 mEq. Clostridium tetani did not grow
in cultures of material taken from the wound on the
hand.

Desensitization procedures were necessary, as the
patient had positive skin reactions to both equine
and bovine tetanus antitoxins. A total of 80,000
units of tetanus antitoxin was administered. The
minor lesions on the left hand were debrided under
local anesthesia. Respiratory distress necessitated
tracheotomy. Chloral hydrate and calcium bromide
were given per rectum for sedation. Diphenhydra-
mine in doses of 50 mg. was injected intramuscu-
larly every six hours as a prophylactic measure
against serum sickness.

Tetanic contractions varied from mild to very se-
vere. On the third hospital day sinus tachycardia of
110 beats per minute developed. As a further meas-

ure against serum sickness 100 mg. of hydrocorti-
sone was given intravenously on the fourth hospital
day, and later the dose was increased to 300 mg.
per day. On the sixth hospital day the pulse rate
had increased to 136 beats per minute, but blood
pressure and urine output remained normal. An
electrocardiogram recorded in the morning of May
11 showed nonspecific ST-T changes as well as sinus
tachycardia of 140 beats per minute. Generalized
tetanic contractions had decreased to occasional
episodes of mild intensity. In the evening of the same
day supraventricular tachycardia of 180 beats per
minute developed and blood pressure dropped to
shock level despite intravenous administration of
metaraminol and 0.12 mg. of lanatoside-C. Although
the heart rate slowed slightly, multifocal premature
ventricular contractions appeared and could not be
controlled by procaine amide. Irregularity of ven-
tricular rhythm was noted to be more pronounced
during episodes of generalized tetanic contractions.
Ventricular fibrillation was a terminal event, and
the patient died May 12, 1960, the eighth hospital
day. Unfortunately, consent for autopsy could not
be obtained.

DISCUSSION

Current evidence indicates that cardiovascular
abnormalities can cause severe problems in patients
receiving either active or prophylactic treatment
with tetanus antitoxin.* In the active disease it has
been postulated that tetanus toxin may affect the
myocardium.3 Serum sickness from tetanus anti-
toxin undoubtedly plays an important role in the
cardiac abnormalities described, namely myocardial
infarction, sinus tachycardia or nodal tachycardia,
prolonged Q-T interval, ST segment elevation and
premature ventricular contractions. In our experi-
ence with some forty cases of tetanus, cardiac com-
plications have constituted a greater problem than
nutrition, electrolyte imbalance, inability to control
contractions and respiratory distress. The combina-
tion of calcium and digitalis is potentially hazardous
if not used with caution; ventricular arrhythmias
have been noted in the absence of both these agents.

Cardiac arrest during a generalized tetanic con-
traction has been previously observed in another
patient. In that case, electrocardiographic monitor-
ing confirmed restoration of sinus rhythm following
cardiac massage, but the patient died of another
episode of cardiac arrest following a moderate gen-
eralized contraction. Routine electrocardiographic
monitoring is likely to reveal more cases of severe
cardiac difficulty in patients with tetanus.

SUMMARY

The fourth reported case of recurrent tetanus
infection in the United States is presented. The re-
port further confirms the statement that neither the

•Reference Nos. 1, 2, 4, 6. 9. 10, 13.

CALIFORNIA MEDICINE

active disease nor a single tetanus toxoid injection
produces lasting or effective immunity. Cardiac
complications may constitute an important cause
of death in patients with tetanus.

Kaiser Foundation Rehabilitation Center, 2600 Alameda Street,
Vallejo (Cain).

REFERENCES

1. Barr, D. P., editor: Modern Medical Therapy in Gen-
eral Practice, Vol. II. The Williams & Wilkins Company,
Baltimore, 1940, pp. 1284-1285.

2. Fox, T. T., and Messeloff, C. R. : Electrocardiographic
changes in a case of serum sickness due to tetanus anti-
toxin, N. Y. State J. Med., 42:152-154, Jan. 15, 1942.

3. Garcia-Palmieri, M. R., and Ramirez, R. : The electro-
cardiogram in tetanus, Am. Heart J., 53:809-813, June 1957.

4. Heintz, R.: Serum sickness following injection of tet-
anus antitoxin in an unusual case of cardiac infarction with
eosinophilic myocarditis, Zeitschr. f. Kreislaufforsch., 40:40-
43, Jan. 1951.

5. Martin, H. L., and McDowell, F. : Recurrent tetanus:
Report of a case, Ann. Int. Med., 41:159-163, July 1954.

6. McManus, J. F., and Lawlor, J. J.: Myocardial in-
farction following the administration of tetanus antitoxin,
New Eng. J. Med., 242:17-19, Jan. 5, 1950.

7. Mobius, L.: Atypical and recurring tetanus, Zeitschr.
f. Kinderheilk., 68:427-436, Sept. 29, 1950.

8. No author: California Public Health Statistical Report,
pp. 20-22, 1959.

9. Queries and minor notes: Tetanus antitoxin or coronary
thrombosis as cause of death, J.A.M.A., 111:1316-1317,
Oct. 1, 1938.

10. Roussak, N. J.: Myocardial infarction during serum
sickness, Brit. Heart J., 16:218-220, April 1954.

11. Speed, K.: Recurring tetanus, Med. and Surg., 2:499,
May 1918.

12. Vener, H. I., and Bower, A. G.: Tetanus: Second
attack with recovery, J.A.M.A., 114:2198-2199, June 1, 1940.

13. Wadsworth, G. H., and Brown, C. H.: Serum reaction
complicated by acute carditis, J. Pediat., 17 :801-805, Dec.
1940.

Arthrodesis of a Knee for
Neuropathic Disease

FRANK E. WINTER, M.O., Visalia

Treatment of neuropathic conditions in weight-
bearing joints has long been a challenge to ortho-
pedic surgeons. In spite of the best possible bracing,
slow disintegration with increasing instability and
incapacitation may occur. Arthrodesis serves best in
these circumstances but has been difficult to attain.
In the case here presented arthrodesis was accom-
plished by using a special clamp which permits
the femur and tibia to be tightly pressed together
for weeks while bony ankylosis is taking place.

The apparatus consists of two 4 mm. Steinman
pins inserted into the femur and tibia, respectively,
at right angles to their shafts and compressed by
the special apparatus devised by Charnley. The
projecting points are held together by screw clamps,
and wing nuts are tightened until the Steinman
pins bow.

REPORT OF A CASE

The patient, a 54-year-old married agricultural
laborer, was first observed August 15, 1958, with
pronounced swelling of the right knee, which the
patient said “gave way” easily but was not very
painful.

Twenty years previously, the patient had had
third degree burns over the posterior aspect of
both lower extremities, necessitating skin grafts
and resulting in some limitation of knee motion.
In 1950 a bale of hay was thrown against his right
knee. No unusual complications arose then, but

Submitted October 6, 1961.

after x-ray films had been taken he was told that
some day an operation would be needed. About a
year previously he had noted gradual swelling of
the knee, then rapidly progressive swelling in the
preceding two months.

About 1942 the patient had a positive reaction
to a serologic test for syphilis. In 1944 he was
treated, apparently with penicillin, once or twice a
week for six months. Following this, the patient
believed, the reaction was negative for syphilis.
He had donated blood on two occasions since then.

Upon physical examination the temperature,
pulse and respirations were within normal limits.
The blood pressure was 190/110 mm. of mercury
in both arms. Some slurring of speech, a suggestion
of euphoria and cardiac abnormalities which a con-
sultant considered suggestive of hypertensive vas-
cular disease with probable aortic dilation, were
observed. Results of neurological examination were
within normal limits except that the pupils were
small and did not react to light or accommodation.

The right knee showed massive effusion and
considerable instability. Scars over both popliteal
areas were well-healed; they caused no limitation
of knee motions.

Paracentesis of the knee had been carried out
elsewhere several times in the previous few months
and the patient was now requesting amputation.

X-ray films of the right knee (Figure 1) con-
firmed the clinical impression of a neuropathic
Charcot joint.

Blood cell count and nonprotein nitrogen content
were within normal limits and a serologic test was
“weakly reactive” for syphilis. No abnormality was
noted in the urine.

Aspiration of the knee was carried out weekly

VOL. 97, NO. 1 • JULY 1962

over the subsequent month, and from 300 to 800
cc. of semi-viscous, yellowish fluid was withdrawn
on each occasion.

On September 16, 1958, a compression arthro-
desis, using the Charnley method and his compres-
sion apparatus, was carried out. At operation the de-
struction of the joint was seen to be greater than
had been suggested on the x-ray films. The menisci
and cruciate ligaments were completely destroyed.
Upon resection of the articular surfaces, however,
the bone appeared fairly healthy, not sclerotic.

After operation the extremity was placed into a
Thomas splint and the postoperative course was un-
eventful. Balanced suspension was continued at
home. On October 20, 1958, six weeks after opera-
tion, patient was readmitted to the hospital, the pins
were removed and the leg was placed into a long leg
cast. X-ray films immediately afterward showed the
bones in satisfactory position, but films taken the
following day showed a half inch separation between
the tibia and the femur (Figure 2). Attempts at
closed reduction under general anesthesia failed and
the knee was reopened on October 24, 1958. There
was considerable distraction although some soft
callus had formed between the fragments. New
Steinman pins were inserted and the Charnley ap-
paratus reapplied. Balanced suspension was used
again. Then, on December 14, 1958, a cast was
applied, this time without removal of the pins.

Four months after the second operation, the cast
and pins were removed and the knee showed solid
fusion, clinically and radiologically, and there was
no pain. A month later, against medical advice, the
patient returned to full-time agricultural labor. He
injured his right ankle in stepping into a ditch
three or four inches deep. There was great swelling
at the joint, but little pain. X-ray films (Figure 3)
showed a pathological fracture and extensive Char-
cot involvement. The fracture was easily reduced
and a cast applied. Healing was satisfactory and the
patient was able to return to work four months
later.

He worked regularly after this, doing agricul-
tural labor, and was handicapped only for jobs re-
quiring squatting or the use of a ladder.

When last observed, May 31, 1961, the patient
had no pain in either the knee or the ankle. Fusion
of the knee (Figure 2) was solid and the only
abnormality noted was slight effusion of the ankle.
The right leg was an inch and a half shorter than
the left and the patient wore extra lifts in the right
shoe to compensate.

DISCUSSION

Results of arthrodesis of “neuropathic knee” have
been notoriously poor by all reported methods.
Charnley,2 in reporting 67 knee fusion operations,

Figure 1. — Antero-posterior and lateral x-ray views of
right knee, August 1958. Note destruction of tibia (medial
aspect) and femoral condyles (posterior).

Figure 2. — Antero-posterior and lateral. May 31, 1961,
showing solid ankylosis.

included only two on neuropathic joints, in one
of which the operation failed. Charnley also cited
a series in which Bado and Novales,2 using the
compression method, obtained fusion in two of
three cases of tabes dorsalis.

Wiseman,4 reviewing reports of arthrodesis for
“neuropathic knee” in 20 cases, noted that the
operation failed in three of eleven cases in which
the compression method was used. In 1958 Vails3
reported ten operations for neuropathic disease of
the knee, with six successful.

209 South Floral, Visalia.

REFERENCES

1. Bado, J. L., and Novales, J. G. (1951) : Apartado de la
Revista, Anales de Ortopedia y Traumatologia.

2. Charnley, J.: Compression arthrodesis of the knee,
J. Bone & Joint Surg., 34-B:187, 1952.

3. Vails, J.: Lady Jones Memorial Lecture, J. Bone &
Joint Surg., 40-B:148, 1958.

4. Wiseman, L. W.: Neurogenic arthritis and the prob-
lems of arthrodesis of the neurogenic knee, Clin. Ortho-
paedics, No. 8:218, 1952.

CALIFORNIA MEDICINE

Retroperitoneal Free Air

LAWRENCE DUCKLER, M.D., Portland, Oregon

Free air in the peritoneal cavity secondary to a
perforated viscus is commonly visualized on roent-
gen films. On the other hand free air in the retro-
peritoneal space is found rarely.

This is the report of a 78-year-old white woman
in whom severe left lower quadrant abdominal

Submitted March 2, 1962.

pain developed during self-administration of an
enema for constipation. Exploratory laparotomy
revealed retroperitoneal feces, gas and fluid behind
the descending colon from the rectosigmoid, which
was ruptured, to the splenic flexure. The rupture
was traumatic and no evidence of inflammatory or
neoplastic disease was noted.

I think the diagnosis of retroperitoneal rupture
of bowel could be made from the roentgen appear-
ance ( Figure 1 ) .

9911 S.W. 62nd Avenue, Portland, Oregon.

Figure 1. — Flat film of abdomen of a 78-year-old woman, showing retroperitoneal gas and feces from a ruptured
sigmoid colon. This is a rare occurrence. The film was made after severe pain developed in the left lower abdominal
quadrant during self-administration of an enema. The gas can he seen in broken streaks, with a considerable bubble
in the flank. The large gas bubbles in the upper abdomen are presumably in the stomach.

VOL. 97, NO. 1 • JULY 1962

^ ^MEDICINE

For information on preparation of manuscript, see advertising page 2

DWIGHT L. WILBUR, M.D Editor

EDGAR WAYBURN, M.D Acting Editor

ROBERT F. EDWARDS . . . Assistant to the Editor

Policy Committee — Editorial Board

OMER W. WHEELER, M.D. . . Riverside

SAMUEL R. SHERMAN, M.D San Francisco

CARL E. ANDERSON, M.D Santa Rosa

JAMES C. DOYLE, M.D Beverly Hills

MATTHEW N. HOSMER, M.D. . • San Francisco

IVAN C. HERON, M.D San Francisco

DWIGHT L. WILBUR, M.D San Francisco

EDITORIAL

Time for Unification

This is the month when the unification of the
medical and osteopathic professions in California
becomes a reality, ending more than 20 years of
effort by representatives of both professions.

Members of the California Medical Association
have been kept abreast of the unification program
by presidential letters which have given the latest
progress. Up-to-date reports on some of the steps
in this progress are set down here as a matter of
review for those who have followed the course of
events and for the information of those who may
have overlooked the earlier communications.

On the educational side, the former osteopathic
college in Los Angeles has changed its name legally
to California College of Medicine and has received
accreditation as a medical school from the Council
on Medical Education and Hospitals of the Ameri-
can Medical Association and from the Association
of American Medical Colleges.

The new medical college will be headed by a dean
who is experienced as former dean of the University
of Arkansas Medical School, Doctor Benjamin
Wells. Doctor Wells has risen to the challenge pre-
sented in creating a topflight faculty and starting
off a new medical school under 1962 conditions.

The school has also issued a number of M.D.
degrees. First to receive this degree were the mem-
bers of the faculty, who were suggested by the
accrediting agencies as entitled to the degree as
teachers at an accredited medical school. Also
granted the M.D. degree were the members of the
1962 graduating class, the first students to be so
honored.

By the time this issue of California Medicine
is in the hands of its readers, additional M.D. de-
grees will have been issued to a number of members
of the California Osteopathic Association whose
records have been examined and who are consid-
ered eligible for the honor. The conferring of these

degrees will take place on July 14 and 15, at which
time each group receiving the new degree will be
given a welcome to the ranks of organized medicine
and a brief orientation program.

Legislatively, several bills have been adopted by
the State Legislature and signed into law. One of
these measures requires that any physician who has
held the D.O. degree and subsequently has received
the M.D. degree shall notify both the Board of Med-
ical Examiners and the Board of Osteopathic Ex-
aminers of his election to practice under one degree
or the other. He will not be allowed to practice
under both. His election will then determine the
proper state board to exercise jurisdiction over him.

Administratively, the former California Osteo-
pathic Association is changing its legal name to
Forty First Medical Society. It will be granted a
charter by the California Medical Association under
the new name. Its members will be all those M.D.’s
formerly affiliated with the C.O.A. who have elected
to practice under the Board of Medical Examiners
and have elected to join the Forty First Medical
Society of the California Medical Association.

The bylaws of this society provide that its mem-
bers may be located in any county of California and
shall not be eligible to join any of the existing
county medical societies until the Forty First gives
permission to do so as a means of dissolving the
society. The move is expected to require several
years’ time as a settling down period.

With the granting of a charter, the Forty First
Medical Society may then report its membership to
the California Medical Association and qualify for
the appropriate number of C.M.A. Councilors and
members of the House of Delegates. Thus the new
society will have proportionate representation from
its very beginning.

The California Medical Association has worked
hand in hand with the California Osteopathic Asso-
ciation toward complete unification. Members of
committees of both associations have labored long

CALIFORNIA MEDICINE

and hard toward this end. The educational and legal
advisors of both groups have done yeoman work in
establishing a proper educational atmosphere and

I in looking ahead at all aspects of the law which

might affect the unification program.

There remains one more step to make this pro-
gram complete — the affirmative vote of the people
of California on Proposition 22 in the Novem-
ber statewide general election. This proposition pro-
vides, in brief, for the cessation of further osteo-
pathic licenses, for assumption of control over all
M.D. licenses by the Board of Medical Examiners
and for the continuation of supervisory powers by
the Board of Osteopathic Examiners until such time
as not more than 40 licentiates are still under the
osteopathic board’s jurisdiction.

If the unification program and the aspirations of
all those associated with it are to be fulfilled, this
proposition must be approved by the voters. Toward
this end, plans have already been made for a posi-
tive and aggressive campaign to insure the passage
of Proposition 22. Committees have been ap-
pointed to work jointly, all public relations facilities
of both organizations have been marshalled, a cam-
paign director has been selected and the raising of
needed funds has been planned. All members of the

Association should throw their weight behind this
campaign.

There will be opposition to this proposition, ema-
nating from national osteopathic headquarters and
represented locally by a small group subservient to
the national organization. The efforts of these oppo-
nents must be more than matched if a satisfactory
vote is to be achieved.

One problem in this effort — which is also one of
the major reasons for the unification — is the public
misunderstanding of the points of similarity or dif-
ference between the M.D. and the D.O. degree. In
some states of our country, an osteopath is severely
limited in his license and does not have the profes-
sional stature that he has in California. Voters who
have come here from areas where that is the case
may not understand that in California the two
groups have been practicing along parallel lines,
under the same state laws, for the past 40 years.

If this misunderstanding is to be erased, much
work must be done. Both the C.M.A. and the C.O.A.
(Forty First Medical Society) are gearing up for
the campaign ahead. All members will be asked to
do their share. The citizens of California are en-
titled to the advantages inherent in this unification.
We must not let them remain uninformed. We must
not let them down.

^ £/ MEDICAL

ASSOCIATION

NOTICES & REPORTS

Council Meeting Minutes

481st Meeting

Minutes of the 481st Meeting of the Council, Los

Angeles , Biltmore Hotel, May 19, 1962.

The meeting was called to order by Chairman
Anderson in the Galeria Room of the Biltmore
Hotel. Los Angeles, on Saturday, May 19, 1962, at
10:00 a.m.

Roll Call:

Present were President Wheeler, President-Elect
Sherman, Speaker Doyle, Vice-Speaker Heron, and
Councilors MacLaggan, Wilson, Todd, Quinn,
O’Neill, Bullock. O’Connor, Ham, Rogers, Dalton,
Davis, Miller. Watts, Morrison, Campbell. Kaiser,
Anderson and Dozier. Doctor Edgar Wayburn at-
tended as editor pro tem. Absent for cause, Editor
Wilbur, Secretary Hosmer, Councilor Murray.

Present by invitation were Messrs. Hunton,
Thomas, Clancy, Collins, Marvin, Whelan, Klutch,
Tobitt and Bowman, Mrs. Griffith and Doctor Mil-
ler of CM A staff; county executives Scheuber of
Alameda-Contra Costa, Lingerfelt of Fresno, Dalbec
and Baker of Los Angeles, Blankford of Marin,
Grove of Monterey, Burris of San Diego, Neick of
San Francisco, Thompson of San Joaquin, Donovan
of Santa Clara. Brown of Sonoma. Bailey of Tulare
and Rideout of Butte-Glenn; Messrs. Hassard and
Huber of legal counsel; Messrs. Read and Salisbury
of the Public Health League; Etchel Paolini of
California Physicians’ Service; Doctors T. Eric
Reynolds, William K. Friend, Eldon E. Smith,
Richard J. Lescoe, Jack W. Baker, Arthur F. Ed-
wards, John C. Brennan, Warren L. Bostick, Dan

0. Kilroy, Stuart Knox, John E. Vaughan, Seymour
Strongin, Richard Miller and others; Dr. W. Bal-
lentine Henley, President of California College of
Medicine; Mr. James E. Bryan, consultant.

A quorum present and acting.

1. Minutes for Approval:

On motions duly made and seconded in each
instance, approval was voted for minutes of the
479th Council meeting, held April 14-17, 1962,
and the 480th Council meeting, held April 18, 1962.

2. Membership:

(a) A report of membership as of May 16, 1962,
was presented and ordered filed.

(b) On motion duly made and seconded, 1,206
delinquent members, dues now paid, were voted
reinstatement.

(c) On motion duly made and seconded in each
instance, 19 applicants were voted Associate Mem-
bership. These were: Robert C. Boullon, Alameda-
Contra Costa; Charles Wm. McLenathen, Arthur
James Moss, Louis Joseph Rosner, Irwin Rubell,
J. Kendall Van Deventer, Edwin T. Wright, Los
Angeles County; Elizabeth Manson, Marin County;
Emir Allen Gaw, Napa County; Morris M. Rubin,
Orange County; Philip J. Schmahl, San Bernardino
County; Albert D. Hall, San Francisco County;
Anne W. Becker, Fitz-John Weddell, Jr., San Luis
Obispo County; Bruce R. Jessup, Richard K. Shaw,
Santa Clara County; Carlton C. Purviance, Solano
County; Donald A. Ballard, Ventura County; Leon
M. Swift, Yuba-Sutter-Colusa.

OMER W. WHEELER, M.D President

SAMUEL R. SHERMAN, M.D President-Elect

JAMES C. DOYLE, M.D Speaker

IVAN C. HERON, M.D Vice-Speaker

CARL E. ANDERSON, M.D. . . Chairman of the Council
BURT L. DAVIS, M.D. . . Vice-Chairman of the Council

MATTHEW N. HOSMER, M.D Secretary

DWIGHT L. WILBUR, M.D Editor

HOWARD HASSARD Executive Director

JOHN HUNTON Executive Secretary

General Office, 693 Sutter Street, San Francisco 2 • PRospect 6-9400

ED CLANCY Director of Public Relations

Southern California Office:

2975 Wilshire Boulevard, Los Angeles 5 • DUnkirk 5-2341

CALIFORNIA MEDICINE

fd) On motion duly made and seconded in each
instance. Retired Membership was voted for Doctors
Emery Laurence Meyers, Butte-Glenn County; Mary
W. Harris, Marin County; and Jean Louis Brinda-
mour, San Francisco County.

(e) On motion duly made and seconded, reduc-
tions of dues were voted for seven members be-
cause of illness or postgraduate study.

(f) Mr. Hassard reported on progress made
toward formation of the Forty First Medical So-
ciety, which intends to be ready to receive a charter,
already authorized, in August, 1962. Details of the
formation of the society were discussed.

3. Report of the President:

Doctor Wheeler reported on recent meetings
with osteopathic leaders and outlined a series of
appearances he had made in recent weeks.

4. Committee for Emergency Action:

Doctor Wheeler reported on a meeting of the
Committee for Emergency Action, at which discus-
sion was held on mass polio immunization pro-
grams.

Doctor MacLaggan went into additional detail
on the immunization programs and urged that
publicity be instituted promptly to the profession
and the public, outlining the desirability of car-
rying out mass programs in the fall months. On
motion duly made and seconded, it was voted to
institute both professional and public releases call-
ing for mass polio inoculation campaigns to be
carried on in the fall months. The release would
outline the health factors, vaccine shortage and
other conditions which indicate undesirability of
summer campaigns, and call on the county societies
for their cooperation under these principles.

5. Reports of Medical Schools:

fa) Councilor Quinn, reporting for Loma Linda
University, outlined a program of expansion being
undertaken by the school, to result in the entire
medical course being taught in Los Angeles.

(b) Doctor Clayton G. Loosli, dean of medicine
at University of Southern California, reported on
a program of expansion, new buildings and other
facilities of the school.

He also reported a strong alumni group working
in behalf of the school and stated that about 85%
of the medical alumni totaling about 2,000 are
residents of areas south of Santa Barbara.

(c) Doctor W. Ballentine Henley, President of
California College of Medicine, expressed his thanks
at attending the meeting, reported that the Cal-
ifornia Osteopathic Association in its annual meet-
ing, just concluded, had amended its bylaws and

taken all other steps preparatory to unification
with the CMA. Doctor Henley also reviewed the
procedures taken for the granting of M.D. degrees
and outlined the program to be followed for com-
mencement and orientation programs.

6. State Department of Public Health:

Doctor Harold M. Erickson, deputy director of
Public Health, reported on the outlook for mass
polio immunization and expressed the desire of
the department to cooperate with the CMA and the
county societies in achieving a high percentage of
coverage in such campaigns.

7. State Department of Mental Hygiene:

Doctor D. C. Gaede of the State Department of
Mental Hygiene gave a progress report on the
department’s long-range plan to transfer mental
health cases into private facilities. He also re-
ported that a day care center is to be opened in
San Francisco following opening of the first center
in San Diego. A third center is planned for Los
Angeles.

8. State Department of Social Welfare:

Doctor Lester McDonald gave a statistical review
of the cases now on welfare rolls, pointing to a
decline in participation in many programs. He also
reported that the Medical Assistance to the Aged
program now has 14,800 recipients, of whom about
30% have not been transferred from other pro-
grams.

9. Report of President-Elect:

Doctor Sherman reported on his recent activities
and appearances and commented on the need for a
wider understanding of the role played by Cal-
ifornia Physicians’ Service. He introduced a reso-
lution which, on motion duly made and seconded,
was voted approval. The resolution reads:

Resolved: That the Council of the California
Medical Association urge and encourage the Board
of Trustees of California Physicians’ Service to
initiate through resolutions to both the Council and
the House of Delegates of CMA, new, improved and
constructive programs of CPS coverage to further
strengthen the position of CPS in the voluntary
prepayment insurance field in the state of Cal-
ifornia to the mutual benefit of the physicians of
California and their patients. This would apply
particularly to new pilot programs for experimen-
tation on a local basis.

10. Committee on Committees:

Doctor Sherman reported for the Committee on
Committees and presented nominations for several

VOL. 97. NO. 1 • JULY 1962

committees, all of which, on motion duly made and
seconded, were approved.

He also called attention to a Bylaw amendment
which eliminated the Committee on Legislation
from the Bylaw structure and proposed that this
be made a special committee of the Council. On
motion duly made and seconded, the Committee on
Legislation was voted to be a special Council com-
mittee, with Dan 0. Kilroy as chairman and Doctors
Stuart C. Knox and Samuel R. Sherman as mem-
bers.

11. California Physicians’ Service:

Doctor John Morrison reported on the program
of the National Blue Shield Commission for medical
coverage of the aged and outlined the manner in
which California Physicians’ Service will partici-
pate.

12. Finance Committee :

Doctor Davis presented a report of income and
expenditures for April and for the ten months ended
April 30, 1962.

Doctor Davis also reported that the committee
had voted to favor an additional bank loan guaran-
tee of $20,000 to assist the California Commission
for Accreditation of Nursing Homes and Related
Facilities in securing working funds. On motion
duly made and seconded, it was voted that the Asso-
ciation guarantee a bank loan up to $20,000 for this
purpose.

13. Bureau of Research and Planning:

Doctor Gerald W. Shaw reported that the Bureau
of Research and Planning was continuing several
studies started earlier and that a report on News-
letter would be prepared for distribution to the
Council prior to its next meeting. A physician fee
index survey already authorized is to be initiated
June 30. The purpose of this study is to determine
the accuracy of the physician fee index component
of the “Medical Care Index” of the U.S. Bureau of
Labor Statistics.

14. Commission on Public Agencies:

Doctor MacLaggan presented a proposed press
release on the subject of mass polio immunization
campaigns which had been discussed earlier. On
motion duly made and seconded, the release was
approved, subject to several outlined amendments.

On motion duly made and seconded, approval
was voted for a guide for polio immunization
campaigns, prepared by staff for distribution to
county societies.

15. Bureau on Communications :

Doctor Warren L. Bostick gave a progress report
on the Bureau on Communications, which he stated

is currently operating as a unit without subcom-
mittees. Various areas of responsibility have been
assigned to individual members of the bureau.

16. Staff Report:

Mr. Hassard requested approval of a statement
prepared by staff on closed chest cardiac resuscita-
tion. On motion duly made and seconded, the state-
ment was voted approval.

17. Legal Counsel:

Mr. Hassard reported that the court had ruled
in favor of defendants’ demurrers in a case brought
by osteopathic interests seeking to block the unifi-
cation program. The plaintiffs still have the right
to appeal.

Mr. Hassard also reported on another court case,
where a physician had been denied a hospital staff
appointment and later, by court order, was given
public hearings on his staff application. The court
has now held that the hospital board — a public
district hospital — has authority to deny staff mem-
bership for cause and that the mere holding of a
valid license to practice does not entitle a physician
to a hospital staff appointment.

Mr. Hassard further reported on an initiative
measure which would provide free medical care for
all residents of California. The measure has been
given a title by the Attorney General and copies
are being circulated in an effort to gain the required
420.000 plus signatures for qualification for the
November election.

18. Standardized Claims Forms:

A recommendation of the Medical Executives
Conference that standardized claims forms as set
up for various county societies was discussed and,
on motion duly made and seconded, approved.

19. 1962 House of Delegates Actions:

The Council reviewed the resolutions resulting
from the 1962 House of Delegates and assigned
various resolutions to several commissions and
committees for study and report back to the Council.

20. AM A 1968 Meeting:

On motion duly made and seconded, it was voted
to invite the American Medical Association to hold
its 1968 annual meeting in San Francisco provided
suitable arrangements can be made.

21. Laboratory Animals:

Councilor Bullock called attention to three bills
now before Congress — HR 3556, HR 1937 and
S 3088 — which would call for stringent restraints on
the use of animals in research where federal funds

CALIFORNIA MEDICINE

are in any way involved. He presented a resolution
calling for opposition to these measures; on motion
duly made and seconded, the Council voted in favor
of the resolution.

22. Future Annual Sessions:

On motion duly made and seconded, the Council
voted to hold the 1963 Annual Session at the
Ambassador Hotel, Los Angeles, from March 24

through March 28 and the 1964 Annual Session
at the Biltmore Hotel, also in Los Angeles, from
March 22 through March 25.

Adjournment:

There being no further business to come before it,
the meeting was adjourned at 4:15 p.m.

Carl E. Anderson, M.D., Chairman
John Hunton, Acting Secretary

3 n jlletnortam

Abdun-Nur, Assed Simon, Tarzana. Died June 16, 1962,
in Encino, aged 75, of metastatic carcinoma of the prostate.
Graduate of Northwestern University Medical School, Chi-
cago, Illinois, 1910. Licensed in California in 1921. Doctor
Abdun-Nur was a retired member of the Los Angeles County
Medical Association and the California Medical Association,
and an associate member of the American Medical Asso-
ciation.

Anderson, James F., Los Angeles. Died May 27, 1962, in
Los Angeles, aged 67, of leukemia. Graduate of the College
of Physicians and Surgeons, Los Angeles, 1917. Licensed in
California in 1917. Doctor Anderson was a member of the
Los Angeles County Medical Association.

Barnard, Harold Dewey, Las Vegas. Died May 7, 1962,
in Las Vegas, aged 75, of carcinoma of the lung. Graduate
of Cooper Medical College, San Francisco, 1912. Licensed
in California in 1912. Doctor Barnard was a retired member
of the Los Angeles County Medical Association and the
California Medical Association, and an associate member of
the American Medical Association.

Boyer, William Francis, Indio. Died June 7, 1962, in
Indio, aged 42, from an accidental gunshot wound. Gradu-
ate of the University of California School of Medicine,
Berkeley-San Francisco, 1943. Licensed in California in
1944. Doctor Boyer was a member of the Riverside County
Medical Association.

Brickley, Paul M., Santa Barbara. Died by drowning,
January 11, 1962, aged 44. Graduate of the University of
Minnesota Medical School, Minneapolis, 1944. Licensed in
California in 1952. Doctor Brickley was a member of the
Santa Barbara County Medical Society.

Cilley, Herbert Arthur, San Jose. Died May 24, 1962,
in San Jose, aged 63, of heart disease. Graduate of Stanford
University School of Medicine, Palo Alto-San Francisco,
1930. Licensed in California in 1930. Doctor Cilley was a
member of the Santa Clara County Medical Society.

Dickinson, Charles Chester, Chico. Died May 24, 1962,
in Chico, aged 72. Graduate of the University of Illinois
College of Medicine, Chicago, 1912. Licensed in California
in 1912. Doctor Dickinson was a member of the Siskiyou
County Medical Society.

Fogel, Edward Theodore, Los Angeles. Died May 14,
1962, in Beverly Hills, aged 56, of heart disease. Graduate
of the University of California School of Medicine, Berkeley-
San Francisco, 1932. Licensed in California in 1932. Doctor
Fogel was a member of the Los Angeles County Medical
Association.

Gray, George Alexander, San Jose. Died June 6, 1962,
in San Jose, aged 69, of heart disease. Graduate of Rush
Medical College, Chicago, Illinois, 1917. Licensed in Cali-
fornia in 1920. Doctor Gray was a member of the Santa
Clara County Medical Society.

Green, George B., Burlingame. Died February 6, 1962, in
Fairfield, Alabama, aged 39, of heart disease. Graduate
of Vanderbilt University School of Medicine, Nashville,
Tennessee, 1949. Licensed in California in 1955. Doctor
Green was a member of the San Mateo County Medical
Society.

Hagen, Horace, Pebble Beach. Died April 26, 1962, in
Pebble Beach, aged 63, of heart disease. Graduate of the
College of Medical Evangelists, Loma Linda-Los Angeles,
1923. Licensed in California in 1924. Doctor Hagen was a
member of the San Luis Obispo County Medical Society.

Lacey, John Mark (J. Mark), La Crescenta. Died May
15, 1962, in La Crescenta, aged 80, of cerebral vascular acci-
dent. Graduate of the University of Illinois College of
Medicine, Chicago, 1914. Licensed in California in 1915.
Doctor Lacey was a retired member of the Los Angeles
County Medical Association and the California Medical
Association, and an associate member of the American
Medical Association.

Leo, Robert J., Visalia. Drowned at sea while fishing,
May 30, 1962, aged 46. Graduate of the College of Medi-
cal Evangelists School of Medicine, Loma Linda-Los An-
geles, 1943. Licensed in California in 1943. Doctor Leo was
a member of the Tulare County Medical Society.

Luke, Ian W., San Mateo. Died May 29, 1962, in Hills-
borough, aged 46. Graduate of Stanford University School
of Medicine, Palo Alto-San Francisco, 1939. Licensed in
California in 1939. Doctor Luke was a member of the San
Mateo County Medical Society.

Mattera, Vincent J., San Diego. Died June 3, 1962, in
San Diego, aged 63. Graduate of Tufts University School of

VOL. 97, NO. 1 • JULY 1962

Medicine, Boston, Massachusetts, 1928. Licensed in Cali-
fornia in 1958. Doctor Mattera was a member of the San
Diego County Medical Society.

Messenger, Thomas T., Avenal. Died May 24, 1962, in
Avenal, aged 59, of heart disease. Graduate of the University
of Arkansas School of Medicine, Little Rock, 1937. Licensed
in California in 1937. Doctor Messenger was a member of
the Kings County Medical Society.

Moore, Chester Biven, Belvedere. Died May 3, 1962, in
San Francisco, aged 80. Graduate of the University of Cali-
fornia School of Medicine, Berkeley-San Francisco, 1910.
Licensed in California in 1910. Doctor Moore was a retired
member of the San Francisco Medical Society and the Cali-
fornia Medical Association, and an associate member of the
American Medical Association.

Morrison, Norman Donald, San Mateo. Died May 27,
1962, in San Mateo, aged 85. Graduate of Cooper Medical
College, San Francisco, 1904. Licensed in California in 1904.
Doctor Morrison was a member of the San Mateo County
Medical Society, a life member of the California Medical
Association, and a member of the American Medical Asso-
ciation.

Muller, Harold P., Berkeley. Died May 17, 1962, in
Berkeley, aged 60, of heart disease. Graduate of the Univer-
sity of California School of Medicine, Berkeley-San Fran-
cisco, 1929. Licensed in California in 1929. Doctor Muller
was a member of the Alameda-Contra Costa Medical Asso-
ciation.

Reeves, Edwin Wiley, Salinas. Died June 10, 1962, aged
72. Graduate of Vanderbilt University School of Medicine,
Nashville, Tennessee, 1917. Licensed in California in 1917.
Doctor Reeves was a member of the Monterey County Medi-
cal Society.

❖

Rose, S. Paul, San Mateo. Died in 1962, aged 48, of
heart disease. Graduate of Howard University School of

Medicine, Washington, D. C., 1942. Licensed in California
in 1959. Doctor Rose was a member of the San Mateo
County Medical Society.

Rush, Richard Cox, San Fernando. Died May 8, 1962,
in San Fernando, aged 74, of heart disease. Graduate of the
Medical College of Alabama, Birmingham, 1902. Licensed
in California in 1915. Doctor Rush was a member of the Los
Angeles County Medical Association.

Simmonds, Raymond J., Sacramento. Died May 7, 1962,
in Sacramento, aged 50. Graduate of the Stanford Univer-
sity School of Medicine, Palo Alto-San Francisco, 1937.
Licensed in California in 1937. Doctor Simmonds was a
member of the Sacramento Medical Society.

Tasher, Dean Charles, San Bernardino. Died May 21,
1962, in San Bernardino, aged 42. Graduate of the Univer-
sity of Chicago, The School of Medicine, Illinois, 1943.
Licensed in California in 1954. Doctor Tasher was a member
of the San Bernardino County Medical Society.

❖

Tirrell, C. Malcolm (Chester), Redlands. Died June 5,
1962, in Redlands, aged 59, of heart disease. Graduate of
Washington University School of Medicine, St. Louis, Mis-
souri, 1928. Licensed in California in 1946. Doctor Tirrell
was a member of the San Bernardino County Medical
Society.

Walthall, Felix Edward, Poway. Died May 3, 1962, in
San Diego, aged 54, of coronary occlusion. Graduate of
Emory University School of Medicine, Atlanta, Georgia,
1934. Licensed in California in 1935. Doctor Walthall was
a member of the San Diego County Medical Society.

❖

Wedell, William John, San Francisco. Died May 19,
1962, aged 44, of cerebral hemorrhage. Graduate of Cornell
University Medical College, New York, New York, 1943.
Licensed in California in 1947. Doctor Wedell was a mem-
ber of the San Francisco Medical Society.

CALIFORNIA MEDICINE

CALIFORNIA MEDICAL ASSOCIATION

1963

annual meeting/

Ambassador Hotel, Los Angeles, March 24-27, 1963

announcing: first call for scientific exhibits.

MEDICAL MOTION PICTURES. SCIENTIFIC PAPERS
THIS IS YOUR MEETING .... PLAN TO PARTICIPATE

Do you have A SCIENTIFIC EXHIBIT? ... A MEDICAL MOTION PICTURE?
. . . Write now to the CMA Committee on Scientific Work, 693 Sutter Street,
San Francisco 2, for application forms for Scientific Exhibits and Medical Motion
Pictures. Don’t wait! Completed application forms must be in this office soon so
that space and time can be allotted.

7 7 7

do \JOli lave A PAPER you’d like to present to your colleagues?

Write to the appropriate Section Secretary . . . Don’t delay
Programs are being planned now!

. Do it today

SECRETARIES OF THE SCIENTIFIC SECTIONS

ALLERGY

Walter R. MacLaren, M.D.

696 East Colorado Street, Pasadena 1

OBSTETRICS AND GYNECOLOGY . . Leon P. Fox, M.D.
303 North 15th Street, San Jose 12

ANESTHESIOLOGY James S. West, M.D.

Box 8914, Los Angeles 8

ORTHOPEDICS Edwin G. Bovill, Jr., M.D.

450 Sutter Street, San Francisco 8

DERMATOLOGY AND

SYPHILOLOGY Herbert L. Joseph, M.D.

1516 Napa Street, Vallejo

EAR, NOSE AND THROAT . . William F. Baxter, M.D.

762 Altos Oaks Drive, Los Altos

EYE James F. Kleckner, M.D.

3731 Stocker Street, Los Angeles 8

GENERAL PRACTICE .... Herbert A. Holden, M.D.

383 West Joaguin Avenue, San Leandro

GENERAL SURGERY David B. Hinshaw, M.D.

Room 9440, 1200 North State Street,

Los Angeles 33

INDUSTRIAL MEDICINE AND

SURGERY Carl E. Nemethi, M.D.

5592 Santa Fe Avenue, Los Angeles 58

PATHOLOGY AND

BACTERIOLOGY Richard O. Myers, M.D.

Valley Presbyterian Hospital, 15107 Vanowen Street,

Van Nuys

PEDIATRICS Lawrence E. Reck, M.D.

2950 Sixth Avenue, San Diego 3

PHYSICAL MEDICINE Frances Baker, M.D.

1 Tilton Avenue, San Mateo

PREVENTIVE MEDICINE AND

PUBLIC HEALTH Herbert Bauer, M.D.

Yolo County Health Department, P.O. Box 532, Woodland

PSYCHIATRY AND NEUROLOGY . Henry S. Colony, M.D.
411 30th Street, Oakland 9

RADIOLOGY Walter Gaines, M.D.

120 St. Matthews Avenue, San Mateo

INTERNAL MEDICINE . . Harney M. Cordua, Jr., M.D.

2561 First Avenue, San Diego 3

UROLOGY

Henry Bodner, M.D.

4911 Van Nuys Boulevard, Van Nuys

VOL. 97, NO. 1

JULY 1962

PUBLIC HEALTH REPORT

MALCOLM H. MERRILL. M.D., M.P.H.
Director, State Department of Public Health

For years, science has probed alcoholics for person-
ality characteristics that would distinguish them
from normal drinkers. So far, these efforts have
been unsuccessful. Alcoholism seems to have no re-
gard for station, rank or breeding. It refuses to be
identified through standard psychological tests and
eludes attempts to classify it as a condition peculiar
to certain groups.

In studying the possible causes of the many alco-
holics which appear to exist in our society, investi-
gators have now turned to behavioral evidence as a
means of distinguishing groups of persons with a
greater risk of becoming alcoholics than others.
Some researchers believe that what friends, neigh-
bors and acquaintances observe about the drinking
behavior of an individual may be the first clues to
the possible onset of alcoholism.

A report on what 100 community leaders in Cali-
fornia think are signs of incipient alcoholism was
prepared by the State Department of Public Health
in 1959, and a sequel was released in May of this
year. The recent report, “The Development of a
Screening Device for Risk Populations,” shows how
the answers of the community leaders were used to
develop a single, brief questionnaire which delves
into a respondent’s physical and emotional com-
plaints, his situational problems and what he does
about them, and his concept of his own personality.

This questionnaire was tested on more than 200
volunteers over a period of five months, and the in-
formation originally obtained from the community
leaders has been substantiated by the questionnaire
results. Besides mentioning the extreme reactions of
some drinkers to daily problems and their propen-
sity for physical and emotional ills, the community
leaders identified many persons with drinking prob-
lems as being “lonely, inadequate, or weak-willed.”
These observations were borne out in the answers
of some of the volunteer respondents to the ques-
tionnaire. who thus could be designated as possibly
more “at risk” of alcoholism than others.

This does not mean that a way has been found
to predict who may become an alcoholic, because
the questionnaire is still a crude implement which
can be applied only to large groups in the popula-

tion. It must be tested further by other investigators
before decisions can be reached on its validity and
eventual use in research on the etiology of alco-
holism.

The report, Publication No. 7 in the Alcoholism
and California series, is available to interested per-
sons from the Division of Alcoholic Rehabilitation,
2151 Berkeley Way, Berkeley.

ill

Pertussis, like diphtheria, is a preventable disease,
yet there are between 2,000 and 4,000 cases and
some deaths reported each year in California.

The deaths occur in children of early age — one-
third of them in infants less than three months of
age, one-half in those less than six months of age
and nearly 90 per cent in those under the age of
two years. Although the same immunizing agent is
used to prevent both diphtheria and pertussis, it is
curious that, comparing the year 1960 with 1950,
diphtheria showed a drop of 99.6 per cent (268
cases in 1950 and 1 in 1960), while pertussis de-
creased only 70.4 per cent (6,613 cases in 1950 and
1,957 in 1960). It is believed that cases and deaths
from both diseases are occurring in unvaccinated
children.

i i i

Official State road tests of devices for control of
automobile exhaust are now under way. This repre-
sents a major break-through in California’s efforts
to control smog, since it is estimated that general
use of effective exhaust control devices could cut
automobile-created air pollution as much as 65 per
cent.

Testing has been started with the installation of
prototypes of three exhaust control devices on 75
“average” automobiles. A fourth device is expected
to be placed for testing on another 25 cars in the
near future. Two of the devices are of the catalytic
type and one is a direct-flame afterburner. The de-
vices were accepted for testing by the State Motor
Vehicle Pollution Control Board.

The cars equipped with these devices will be
driven under a variety of conditions for at least
12,000 miles each to test for effectiveness, safety,
noise, odor and durability. The tests will take ap-
proximately nine months to complete.

CALIFORNIA MEDICINE

INFORMATION

A Iwo-year survey result — ending some 18 months
ago and just released — reveals that 68 per cent of
all short-stay hospital discharges had hospitalization
coverage. Insurance paid three-fourths or more of
the hill for over 75 per cent of those covered.

One-half of the discharges in the 65+ age group
were covered. Almost 60 per cent of this group had
three-fourths or more of the hospital hill paid by
voluntary health insurance.

The 65+ group with family income under $4,000
had better protection than age groups under age 45.

The highest per cent of coverage was in the 45 to
64 age group where over 75 per cent of the dis-
charges had coverage, with insurance paying more
than three-fourths of the hill. This is the group
which is likely to retain coverage upon retirement.

HOSPITAL BILLS

What Portion Is Paid by
Insurance?

A Report of the Bureau of Research and
Planning, California Medical Association

A REPORT based upon data collected through house-
hold interviews over a two-year period (July 1958
to June 1960) in the U. S. National Health Survey*
contains information on the extent of hospitaliza-
tion coverage for persons discharged from short-
stay hospitals.

The following tables represent a few of the high-
lights of the recently published report.

Table 1 reveals that among all persons discharged,
68 per cent had some portion of the hospital bill
paid by voluntary health insurance, with 51 per cent
reporting that three-fourths or more of the bill was
paid. Slightly more than half of all persons aged 65
and over had hospital coverage at that time, with 30
per cent reporting that three-fourths or more of the

•Source: U. S. Dept. HEW, Health Statistics, Series B, No. 30,
Nov. 1961.

bill was paid. Thus, in the 65+ group, almost
60 per cent of all persons with coverage who were
discharged from hospital had three-fourths or more
of the bill paid by insurance.

A revealing statistic is that in 76 per cent of dis-
charges in the 45 to 64 age group the patients had
coverage for hospitalization. Approximately 75 per
cent of this group had three-fourths or more of the
bill paid. This is the group in which continuation
of coverage and conversion upon retirement has
shown the most rapid progress, according to the
Health Insurance Council. (A study by the Depart-
ment of Health, Education, and Welfare analyzing
coverage under collectively bargained plans dis-
closes that in more than 95 per cent of collectively
bargained group plans, older workers may maintain
health insurance coverage upon retirement.)

The report states that: “For approximately 32 per
cent of the hospital discharges it was reported that

TABLE 1. — Per cent of persons discharged from short-stay hospitals who had any insurance payment for the hospital bill, the per
cent who had three-fourths or more of their bill paid by insurance, and the per cent of those with any insurance payment who had three-
fourths or more of the bill paid by insurance I United States, July 7958 to June 19601.

Both Sexes

All Ages

Under 15

15 to 44

45 to 64

65+

Total discharges:

1. Per cent with any insurance payment for the bill

68.0

72.1

66.9

76.0

51.2

2. Per cent with three-fourths or more of bill paid
insurance

51.3

58.3

50.6

58.0

30.3

Per cent of discharges with any insurance payment who had
three-fourths or more of the bill paid by insurance (line
2 -*■ line 1)

75.4

80.9

75.6

76.3

59.2

TABLE 2. — Per cent of discharges for some insurance payment for the hospital bill, grouped by annual family income: Discharges

from short-stay hospitals (United States, July 7958 to June 19601.

Both Sexes

All Ages Under 1.5 15 to 44. 45 to 64 65-f

Family income :

All incomes

68.0

72.1

66.9

76.0

51.2

Under $2,000

39.6

32.9

33.0

50.1

42.7

$2,000 to $3,999

59.2

59.4

54.7

71.7

59.8

$4,000 to $6,999

79.0

81.1

78.0

83.8

63.5

$7,000+

81.0

80.4

81.3

89.0

51.1

1 nknown

58.8

71.9

51.2

69.4

45.6

VOL. 97, NO. 1 • JULY 1962

there was not any insurance payment for the hos-
pital bill. It should be noted that this does not mean
that for almost one-third of the hospital discharges
these individuals had to pay for the entire hospital
bill out of their own or their family’s funds. Sources
other than insurance are used to help finance the
cost of hospital care. In addition to the hospital
care provided for veterans by the Veterans Adminis-
tration . . ., the federal government provides care
for other groups such as dependents of members of
the Armed Forces, merchant seamen, and American
Indians. State and local governments, health agen-
cies, and charitable organizations spend large sums
to help finance the cost of hospital services, and,
finally, friends, neighbors, relatives, and employers
on many occasions help to share the burden of a
large hospital bill.”

Table 2 indicates the percentage of discharges, by

age and income group, in which insurance paid
some portion or all of the bill. As previously indi-
cated, in 68 per cent of all discharges insurance pay-
ment covered some portions of expenses. The greater
the family income, the larger was the proportion of
discharges covered by insurance. In the $2,000 to
$3,999 income group, persons 65 and over had a
better rate of coverage than did persons under 45
years of age. Significantly, in the lowest income
group (under $2,000) persons aged 65 and over had
a higher rate than persons under 45.

It should be noted that the foregoing data reflect
information secured up to 18 months ago. Progress
in coverage for the total population has been signifi-
cant, with enrollment of persons 65 and over repre-
senting the most striking gains, according to the
Health Insurance Council.

California Medical Association, 693 Sutter Street, San Francisco 2.

CALIFORNIA MEDICINE

To EACH OF YOU — please accept our special greet-
ings from YOUR State Auxiliary.

It has been a busy few weeks since Convention
in San Francisco. Weeks filled with planning, with
coordinating, and with traveling ... all of which
have been tremendously interesting.

Planning — for the year ahead, but especially for
the Fall Conference to be held in Palm Springs at
the Riviera Hotel, September 25, 26. 27, 1962, with
Mrs. Arthur T. Bailey, Chairman. This Conference
is a work-shop type meeting for the State officers
and chairmen and for the County presidents and
presidents-elect. Invitations will also be extended to
members of the county boards who may wish to
attend.

Coordinating — the year’s work with the state
board officers and chairmen. Outlining activities
and setting up the articles for the annual Year
Book, being compiled by the state corresponding
secretary, Mrs. Paul E. Travis, to be ready for dis-
tribution at Fall Conference. This Year Book is
published by the California Medical Association
under the direction of the Auxiliary liaison officer,
Mr. Jack B. Collins.

Traveling — to visit the component county Aux-
iliaries, which is the privilege of the President of
the Woman’s Auxiliary to the California Medical
Association. It is indeed a genuine pleasure, during
the year, to visit the members in their home coun-
ties; to hear the reports of accomplished projects;
and to listen to plans for even greater auxiliary
activities.

On one trip I drove 2,018 miles from Los An-
geles to the northernmost part of our beautiful state.
Solano County was my first visit. Dropping south

again, I visited San Mateo County, then up to
Placer-Nevada County where the Auxiliary met in
a joint meeting with the County Medical Associa-
tion. Driving north around the very large Clear
Lake, I was reminded of parts of Switzerland —
where little towns nestle at the lake’s edge. The red-
woods in the mist provided a delightful mood as I
entered Humboldt-Del Norte County for its meet-
ing in Eureka. A five-hour drive through the scenic
Trinity National Forest took me to Redding for a
joint meeting with the Shasta-Trinity and Tehama
Counties. Santa Cruz County was next on my itin-
erary, and then on to San Luis Obispo County . . .
another Auxiliary which meets jointly with its
County Medical Association.

It was my privilege to install the officers of my
own Los Angeles County Auxiliary during a two-
day “visit” at home. Two other trips, by plane, took
me to Marin County and to Contra Costa County
Auxiliaries.

I wish I had the space to tell you in detail about
these meetings; of the friendliness; of the tremen-
dous amount of work which is being accomplished;
and of the energetic, enthusiastic members — physi-
cians’ wives — serving their County Medical Asso-
ciations in an effective manner.

This is your Auxiliary.

Is your wife a member? We need her!

It is my hope that your County Medical Associa-
tion gives YOUR County Auxiliary its fullest sup-
port !

Mrs. Floyd K. Anderson
President, Woman’s Auxiliary to the
California Medical Association

VOL. 97. NO. 1

JULY 1962

NEWS & NOTES

NATIONAL • STATE • COUNTY

ALAMEDA

New patients are now being accepted into the preschool
deaf program at Children’s Hospital of the East Bay.
The program has been established to provide professional
assistance to parents of preschool deaf and hard-of-hearing
children so an early beginning can be made in helping
them to communicate through speech and lip reading.

The program includes diagnostic, therapeutic, educa-
tional and counseling services. Education of the parents
is emphasized, so the parents can continue the therapy
techniques at home.

Further information may be obtained by writing or calling
Mr. Ray V. Lage, director, preschool deaf program, Chil-
dren’s Hospital of the East Bay, 51st and Grove Streets,
Oakland 9, California.

LOS ANGELES

Appointment of Dr. Sherman Mellinkoff as dean of
the University of California at Los Angeles School of
Medicine was announced recently. He succeeded Dr. Staf-
ford Warren, who on July 1 assumed the new post of vice
chancellor, health sciences.

The new dean, who received his M.D. degree from Stan-
ford University School of Medicine in 1944, has been a
member of the U.C.L.A. medical school faculty since 1953
when he joined the staff as assistant professor of medicine.

S>: >jc Jj:

The Los Angeles Pediatric Society will present its
nineteenth Brennemann Lecture Series November 7 and
8, 1962, at the Ambassador Hotel. Guest speakers will be
Dr. Albert B. Sabin, Children’s Hospital Research Foun-
dation, Cincinnati, and Dr. Malcolm A. Holliday, De-
partment of Pediatrics, Children’s Hospital. Pittsburgh.

RIVERSIDE

Dr. Peter Lewis, Riverside, has been installed as presi-
dent of the Riverside County Heart Association and Dr.
Roger Ridley has been elected president-elect.

SAN FRANCISCO

The appointment of Dr. Harry Leeb as director of the
San Francisco VA Regional Office Outpatient Clinic at 49
Fourth Street was announced recently. Dr. Leeb was a
medical staff member at the Oakland VA Hospital for
several years. Immediately before his recent appointment
he was a deputy commander of a 1,000-bed reserve hospital
centered at the Hamilton Air Force Base.

SANTA CLARA

Two new research centers for the investigation of
human diseases — including the first ever established by
the National Institutes of Health for the study of pre-

mature infants — will be set up at Stanford Medical Center
with grants totaling $797,305 from the United States Public
Health Service.

The new grants make Stanford University School of
Medicine the first medical school in the country to have
three NIH-supported clinical research centers. Investigations
of new methods of treating cancer with x-rays and other
radiation are already under way with a $943,412 federal
grant announced last year.

The study of premature infants will be financed with a
$267,305 grant. The remaining $530,000 will support a
general research facility in which certain major prob-
lems such as tissue grafting, growth and development,
function of the nervous system, and resistance and suscepti-
bility to infection will be attacked over several years.

First patients will be admitted to the Clinical Research
Center for Premature Infants after August 1. The General
Clinical Research Center will open in midwinter with 16
beds. The grants for both centers cover full hospitalization
expenses of patients who are admitted to the units.

% sjs Hfi

Stanford University’s Lane Medical Library is to

receive $135,837 from the estate of Margaret L. Potter,
who worked at the library for 40 years. Miss Potter died
a little more than a year ago. Her will put no restrictions on
how the bequest was to be used.

The University will use the money to endow The Mar-
garet L. Potter Fund, and will allocate the perpetual
income to the Lane Library.

Under the terms of the special five-year grant of the
Ford Foundation to Stanford in 1960, Miss Potter’s bequest
will bring an additional $45,279 to Stanford. The Founda-
tion is providing one dollar for each three dollars given
to the University during the life of the grant.

GENERAL

Availability of alphabetical lists of registered nurses,
county by county, has been announced by the California
Board of Nursing Education and Nurse Registration. The
lists for all the counties may be obtained from the Board at
1021 O Street, Sacramento 14. The combined directory for
all the counties in the state will cost forty dollars, and lists
for any of the counties separately are available at 50 cents a
page.

* * *

The American Urological Association has announced
the opening of competition for its annual award of $1000
for essays on the result of some clinical or laboratory
research in urology (first prize of $250 for clinical research,
first prize of $250 for laboratory research; second prize of
$150 for clinical research, second prize of $150 for labora-
tory research; third prize of $100 for clinical research;
third prize of $100 for laboratory research) .

Competition is limited to urologists who have been
graduated not more than ten years, and to hospital interns
and residents doing clinical or laboratory research work
in Urology. Animal research is not necessary.

The first two first prize essays will appear on the program
of the meeting of the American Urological Association to
be held at the Sheraton-Jefferson Hotel, St. Louis, May
13-16, 1963.

Full particulars may be obtained from the executive
secretary of the Association, William P. Didusch, 1120 N.
Charles Street, Baltimore 1, Maryland. Essays must be in
his hands before November 15, 1962.

CALIFORNIA MEDICINE

AN ATLAS OF HEAD AND NECK SURGERY— John

M. Lore, Jr., M.D., F.A.C.S., Attending Surgeon, Good
Samaritan Hospital, Suffern, New York; Associate At-
tending Surgeon, Head and Neck Service, Department of
Surgery, Saint Clare's Hospital, New York, N. Y.; Con-
sultant Surgeon, Tuxedo Memorial Hospital, Tuxedo,

N. Y. Illustrated by Robert Wabnitz, Director of Medical
Illustration, University of Rochester Medical Center,
Rochester, N. Y. W. B. Saunders Company, Philadelphia,
Pa., 1962. 490 pages, $25.00.

This atlas of head and neck surgery has three features
which will be of interest and concern to those seeking a
good book on head and neck surgery. These features are:

1. A general surgical rather than a specialty approach
to the problems of head and neck surgery.

2. A new format in medical books consisting of illustra-
tions on one page and brief descriptive comments on the
illustrations step by step on the opposite page. These two
pages face each other so that one need not turn the page
to get the complete message from the excellent illustrations.

3. The cost of $25.00 for a book of regional surgical
scope.

The concept of approaching head and neck surgery from
a general rather than a specialty standpoint has resulted
in a book which bridges the barriers between specialties.
Indeed, plastic surgery, general surgery, neurosurgery and
traumatic surgery of the head and neck are reasonably
well presented in their major attributes. The book con-
cludes a sectional radiographic anatomy, a chapter on
general operative procedures, and then proceeds to cover
topics of the sinuses, nose, fractures of the facial bones,
face, eyelids, ears, lips, parotid and salivary tumors, neck,
thyroid and parathyroid, larynx, esophagus and even vas-
cular surgery of the head and neck of superior medias-
tinum. There is no theoretical discussion offered in the text,
no interpretation of current practices and methods. There
is merely a recounting of the good procedures that the
author has found most useful in each of these areas in
his extensive experience.

The format of the book is beautiful and unique, with
all the illustrations being done by one artist and being
presented in a uniform style. On the side opposite the
excellent illustrations the technical steps and high points
of the operative procedure are detailed step by step, and
each step corresponds numerically to an illustration on
the opposite page which depicts the operative procedure
as it progresses. This makes the visual presentation of
material excellent, straightforward and practical. There is
minimal discussion. The illustrations are beautiful and done
on superb quality paper. The cost of $25.00 seems at first
startling, but if one recognizes the beauty of illustrations
and the quality of paper on which they are presented the
cost dwindles in significance.

The author is to be commended on excellent illustrative
work of the major aspects of head and neck surgery, and

for bridging the barriers between the various specialties
of general, plastic, otorhinological and vascular surgery
and problems of the head and neck. The book can be
recommended as an excellent reference book for surgical
techniques in head and neck surgery.

Victor Richards, M.D.

INTERNAL MEDICINE IN WORLD WAR II— Volume
I, Activities of Medical Consultants (Medical Department,
United States Army) — Prepared and published under the
direction ot Lieutenant General Leonard D. Heaton, The
Surgeon General, United States Army, Colonel John Boyd
Coates, Jr., MC, Editor in Chief, and W. Paul Havens,
Jr., M.D., Editor for Internal Medicine. Office of the
Surgeon General, Department of the Army, Washington,
D. C., 1961. For sale by the Superintendent of Documents,
U. S. Government Printing Office, Washington 25, D. C.
Price $7.50 (Buckram). 880 pages.

To many of us the work of the consultants in World War
II was probably the most important single factor in the
maintenance of a high standard of medical practice through-
out the army. This book gives an informative and frank
account of the work of the consultants in Medicine both in
the service commands and in the theaters of operation
during this period. The various authors, consultants all, do
not hesitate to criticize both the Army at large and the
Army Medical Corps, when criticism is indicated, and at
the same time, point out the shortcomings of many civilian
doctors in their army duties. It was particularly pleased
to find universal condemnation of those chiefs of service
who confined themselves to paper work instead of getting
out on the wards and practicing medicine.

I recommend this volume as entertaining and nostalgic
reading for all who served in the Army Medical Corps and
as a source of valuable information for those interested
in the proper functioning of doctors in the U. S. Army.

G. B. Robson, M.D.

VECTOR ELECTROCARDIOGRAPHY — Herman N.
Uhley, M.D. , Assistant Chief, Department of Medicine,
Mount Zion Hospital and Medical Center, San Francisco,
California. .T. B. Lippincott Company, East Washington
Square, Philadelphia 5, Pa., 1962. 339 pages, $8.50.

This textbook demonstrates admirably the derivation of
the vectorcardiogram from the electrocardiogram and vice
versa. The fundamentals of the formation of the common
patterns encountered in electrocardiography are illustrated
in the form of “live” movies. Each frame is explained in
simple straightforward fashion so that the reader can
formulate a conceptual basis as each pattern unfolds. The
only criticism of the book is the small size of the sketches.

In summary, this book will serve as a highly-recom-
mended introductory text for those beginning vector-
cardiography and for those who would like a unique way
of teaching vectorcardiography and electrocardiography.

Joseph Kaufman, M.D.

VOL. 97. NO. 1

JULY 1962

POSTPARTUM PSYCHIATRIC PROB L EM S — James
Alexander Hamilton, Ph.D., M.D., Associate Clinical Pro-
fessor of Psychiatry, Stanford University School of
Medicine, Stanford, California, Chief of Service, Psychi-
atry, Saint Francis Memorial Hospital, San Francisco,
California. The C. V. Mosby Company, 3207 Washington
Boulevard, St. Louis 3, Mo., 1962. 156 pages, $6.85.

Dr. Hamilton succeeds quite noticeably with at least two
of the three avowed aims of his book. In his effort to
provide the obstetrician, general practitioner, or pedia-
trician with diagnostic criteria and clinical data to help
them recognize postpartum psychiatric reactions, he is quite
successful. In collecting and integrating widely scattered
information bearing on the diagnosis and treatment of post-
partum psychiatric problems and in further emphasizing
the significance of postpartum psychiatric illness, he has
done a noteworthy job. In his effort to identify and sub-
stantiate physiological factors in the etiology of postpartum
mental illness, he is noticeably less successful. This brief
hut comprehensive book is lucidly written and excellently
organized in a way which makes reading it both as a
reference material or for general information equally
feasible. The author has sifted through the literature and
has referred to most of the significant works of the past
200 years. He draws proper attention to the fact that there
has been little in the way of critical study of postpartum
psychiatric reactions. The author has briefly mentioned
those studies which he finds most informative to his points
of view and has, I feel, pointed out the proper areas for
additional research.

Although written by a psychiatrist, presumably for
psychiatrists as well as other physicians, the level of
psychiatric sophistication is rather prosaic. In his efforts
to be comprehensive about treatment methods for the non-
psychiatric physician, he is quite inconsistent and contra-
dictory. For example, at times he emphasizes the necessity
for the use of electric shock therapy in postpartum re-
actions and subsequently mentions the contraindications
which make it quite unfeasible for use in the first weeks
of the puerperium.

One noteworthy factor of Dr. Hamilton's work is his
recognition of the limitations of his own hypotheses. In the
final chapters of his book he points out that his sup-
positions suffer from the same lack of validation and
scientific control as those studies which he has criticized
earlier in the body of his work which do not agree with
his basically physiological theory of the etiology of post-
partum psychiatric illness. There are, however, two major
areas which seem conspicuously absent from a work of this
type, which attempts to deal comprehensively with post-
partum psychiatric problems. The first is the growing body
of careful work, such as that of Bibring and her co-
workers, which shows that normal pregnancy constitutes a
major psychiatric stress to the otherwise emotionally healthy
and well-integrated personality. Furthermore, the author
gives very short shrift to those clinicians who feel that
antepartum psychiatric difficulties are always prominent in
those patients who develop puerperal psychoses. The signif-
icance of the antepartum emotional stresses inherent in
normal pregnancy are primarily in the direction of a
psychogenic etiology. They do not, however, exclude a
physiological component to puerperal illness, and it may
be that this illness can best be understood as a psycho-
physiologic reaction. Another criticism of the author’s
presentation is his failure to emphasize the effects of
physical treatment modalities and pharmacologic agents on
target symptoms rather than on disease entities. This is
most striking in his consideration of the effects of triiodo-
thyronine in treatment of postpartum psychoses. He tends
to use it as a specific remedy, although he overlooks the

normal psychological effects of thyroid hormone as a
stimulant and later suggests that the drug is contra-
indicated in those postpartum syndromes characterized by
excitement and delirium. It would seem probable that the
effects of thyroid hormone on depressed states might well
be related to those stimulating psychological effects rather
than a more esoteric relationship to puerperal illness.

The author presents some very provocative endocrino-
logical work which might elucidate a physiologic etiology
for this illness. He makes the point that the acute mani-
festations of postpartum psychiatric reactions ordinarily
have a two to four day latent period following birth before
they manifest themselves, and he relates this to a presumed
organic cause. There are other events, notably the de-
pressions which occur following total laryngectomy, which
have the same three to four day latent period, which have
presumably no definable organic cause. Finally, in speak-
ing with women who have suffered postpartum depression
of a less than psychotic degree, one is struck by the fact
that they most frequently relate their affect to environ-
mental stresses, changes in self-concept, or interpersonal
relationships, and do not manifest the bewilderment as to
the cause of their reactions which is so prominent in
organically caused psychoses. The chapters describing the
psychodynamics of the postpartum adjustment and the
treatment of postpartum sexual problems are particularly
lucid and would in themselves well justify the reading of
Dr. Hamilton’s book.

Joshua S. Golden, M.D.

RADIOACTIVE ISOTOPES IN MEDICINE AND
BIOLOGY: MEDICINE — Second Edition — Solomon Silver,
M.D., Attending Physician; Chief, Thyroid Clinic, The
Mount Sinai Hospital; Associate Clinical Professor of
Medicine, College of Physicians and Surg'eons, Columbia
University, New York. Lea & Febiger, Washington
Square, Philadelphia 6, Pa., 1962. 347 pages, 49 illustra-
tions, $8.00.

In phase with the expansion in the medical uses of
radioactive isotopes, one of the best books in the field,
“Radioactive Isotopes in Clinical Practice,” by Quimby,
Feitelberg and Silver, has in its second edition expanded
to two volumes: “Basic Physics and Instrumentation,” by
Quimby and Feitelberg, and this work on medical applica-
tions by Dr. Silver, who is associated with Mt. Sinai Hos-
pital and Columbia University in New York.

By leaving the discussion of physics to his colleagues,
Dr. Silver has more space to consider in detail the clinical
applications of isotopes. About half the book is devoted to
the physiology, diagnosis and treatment of the thyroid
and its disorders. Radioactive iodine was among the first,
and is still by far the most important of the artificial
isotopes in its clinical applications. This is a fine sum-
mary of our present understanding of the thyroid and its
many ways of misbehaving.

Dr. Silver has absorbed an enormous mass of literature,
digested it, and produced lucid and up-to-date discussions
of iron kinetics and other hematological applications, meas-
urements of body fluid and electrolyte components, cir-
culation studies, isotope treatment of malignancies, and
the latest in kidney and liver functions and scanning of
individual organs. Some of the elements now finding clinical
use have the ring of science-fiction — iridium, rubidium, tan-
talum, krypton, lutecium — indeed this entire field of medi-
cine was little more than science-fiction sixteen years ago.

This is a well-written book on a subject of ever-increasing
importance, with a balanced presentation of fundamental
physiology and clinical applications. It is highly recom-
mended to users of radioactive isotopes.

Jerold M. Lowenstein, M.D.

CALIFORNIA MEDICINE

the first comprehensive
regulator ofi
female cyclic function

ENOVID*

(brand of norethynodrel with ethynylestradiol 3-methyl ether)

Simple adjustments of the dosage schedule with this versatile thera-
peutic agent enable the physician to: control dysfunctional uterine
bleeding , regulate an abnormal menstrual cycle, enhance or suspend
fertility, advance or postpone the menses, correct endometriosis often
without surgery.

The Basic Action. Enovid (1) induces and
maintains a pseudodecidual endometrium,
preventing uterine bleeding, (2) inhibits pi-
tuitary gonadotropin, preventing ovulation.
When Enovid is withdrawn, bleeding occurs
in about three days and usually resembles a
normal menstrual period in duration and
volume of flow.

Cyclic Enovid Therapy. When Enovid is
prescribed for 20 days of each cycle, commenc-
ing on day 5, the menstrual cycle will adjust
to about 28 days regardless of menstrual tim-
ing prior to Enovid therapy. A few cycles of
therapy will frequently restore a normal pat-
tern to women with irregularities as menor-
rhagia, metrorrhagia or secondary amenorrhea.
Since ovulation is inhibited, Enovid may be
prescribed cyclically over prolonged periods
to suspend fertility. During Enovid therapy
the ovary remains in a state of physiologic
rest. After discontinuance of the drug the
normal ovulatory pattern returns. Indeed,
subsequent pregnancy appears to be enhanced
through a probable “rebound” phenomenon.
Thus, cyclic Enovid administration has been
successful in treating endocrine infertility.
Continuous Enovid Therapy. When Enovid
is given on a continuous dosage basis, men-
struation as well as ovulation is completely
suspended. In endometriosis, continuous
Enovid therapy produces a pseudodecidual
reaction with subsequent absorption of aber-
rant endometrial tissue. This often eliminates
the need for radical surgery. When surgery is
indicated, Enovid is an effective adjunct pre-
operatively, as well as postoperatively, to
prevent recurrence.

Continuous administration of Enovid is also
utilized in habitual abortion, providing bal-

anced hormonal support of the endometrium
and permitting continuation of pregnancy.

Emergency Enovid Therapy. In high doses,
Enovid has a prompt hemostatic effect and
will usually control severe dysfunctional uter-
ine bleeding within 6 to 24 hours. Prompt,
high-dosage administration of Enovid is also
a rational recourse in threatened abortion.

A Note on Safety. The effects of Enovid have
been studied in more than 3,500 women dur-
ing more than 49,500 menstrual cycles, repre-
senting 3,800 woman-years of experience.
Enovid has been administered cyclically to the
same patients for as long as five and one-halt
years for ovulation inhibition without serious
complication. For the present, however, Eno-
vid is not recommended for more than two
years, although it is expected that this period
will be lengthened as experience continues to
accumulate. There has been no impairment
of subsequent fertility and no effect on chil-
dren born to women who conceived after dis-
continuing Enovid therapy.

The basic dosage of Enovid is 5 mg. daily
in cyclic therapy, beginning on day 5 through
day 24 (20 daily doses) . Higher doses may be
used to prevent or to control occasional “spot-
ting” or breakthrough bleeding during Enovid
therapy or for rapid effect in the emergency
treatment of dysfunctional uterine bleeding
or threatened abortion.

Enovid is available in tablets of 5 mg. and of
10 mg. Available on request: literature and
references covering more than six years of
intensive clinical study.

SEARLE

Research in the Service of Medicine

G. D. Searle 8c Co., P.O. Box 5110, Chicago 80, 111.

Advertising • JULY 1962

Measles Immunity May Not
Depend on Reexposure

The persistence of immunity to measles after an
individual has had the disease apparently does not
depend on repeated exposure to the measles virus,
three New York City researchers said recently.

If true, they said, a single vaccination against
measles may provide lifetime immunity.

Samuel Karelitz, M.D., Floyd S. Markham, Ph.D.,
and James M. Ruegsegger, M.D., made a study of
measles immunity among 49 adults and reported
their findings in the May American Journal of Dis-
eases of Children, published by the American Medi-
cal Association.

The level of immunity to measles was determined
among 25 pediatricians who had been repeatedly
exposed to measles-infected children and among 27
other adults, none of whom was known to have been
exposed to measles during the preceding five years,
the authors said.

When the degree of immunity between the two
groups was compared, they said, there was no sig-
nificant difference.

“The exact mechanism of persistent immunity to
the measles virus has not yet been established,” the
researchers concluded. “It appears, however, that
repeated reexposure to persons with clinical measles
is not the answer. Hopefully this may suggest that a

single vaccination with live measles virus vaccine
may suffice. Time will tell whether this is so.”
Development of both live and killed measles virus
vaccines is in the experimental stage.

Antibacterial Drugs Prevent
Travelers' Bane

(Continued from Page 29)

ular medicine used by travelers, iodochlorhydroxy-
quin, “was no more effective than a placebo.

In its mildest form, tourist diarrhea does not
interfere with the traveler’s activities, they said.
However, in its more severe form, they said, it is
complicated by nausea, vomiting, fever, chills,
cramps and joint and muscle pains and may produce
serious complications in the debilitated. The illness
generally lasts from one to three days, but may
persist for a week or more, they said.

No harmful side effects were observed with either
drug during the study, the researchers said. How-
ever, they stressed that those taking drugs were
young, healthy, free from any drug allergy and were
subject to daily scrutiny while the drug was ad-
ministered in low doses for only two weeks.

“It requires no great medical sagacity to predict
that if such drugs are administered without adequate
precautions to the half-million annual visitors to
Mexico, toxic symptoms will occur,” they said.

Office Space for the Professional Man

SAN JOSE - — Fastest growing area in Northern
California. Surrounded by sub divisions, shopping
centers and modern schools. No medical building
within miles.

Access to two

of the most important freeways.
2200 SQUARE FEET

• Will install plumbing for tenants' requirements.

• Will adjust partitions to suit tenants' needs.

Built by one of the leading contractors
in Santa Clara County.

For information write

W. C. GARCIA & ASSOCIATES
5460 Dellwood Way
San Jose, California
Phone: ANdrews 9-1363

CALIFORNIA MEDICINE

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you can strengthen your patient’s will
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The small, odorless, tasteless tablets
ensure patient cooperation.

A heart that had stopped beating was restarted by
a sharp blow to the chest, Dr. Felix Feraru, New
York City, reported recently.

Writing in the May 19 Journal of the American
Medical Association, Dr. Feraru said he struck a
sharp blow with the side of his clenched fist to the
chest of a patient whose heart stopped beating dur-
ing abdominal surgery. The heartbeat resumed
immediately, he said, but subsequently stopped again
and was again restarted by two similar blows to the
chest overlying the heart.

When the patient’s heart stopped beating a third
time, he said, the chest was opened and the heart
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Niacinamide (Vitamin B,) 5.0 mg

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Calcium Lactate 270.0 mg

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Copper (as Sulfate) 0.15 mg

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Vaginal Thrush Treated with Bis-2-Hydroxy-5-Chloro-
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Lancet — Vol. 1:506 (March 10) 1962.

Bis-2-hydroxy-5-chlorophenyl sulfide was investigated in
the treatment of monilial vaginitis (32 cases) and found to
compare favorably with gentian violet paintings and nysta-
tin (fungicidin) (28 cases).

COOK COUNTY

graduate school of medicine

CONTINUING EDUCATION COURSES
STARTING DATES— FALL, 1962

Surgical Technic Two Weeks, Sept. 10, Nov. 5

Surgery of Colon & Rectum One Week, Sept. 17

Urology Two Weeks, Oct. 29

Vaginal Approach to Pelvic Surgery One Week, Sept. 10
Obstetrics, General & Surgical Two Weeks, Oct. 8

Gynecology, Office & Operative Two Weeks, Sept. 17
Proctoscopy & Sigmoidoscopy One Week, Sept. 10

General Practice Review One Week, Oct. 8

Gallbladder Surgery 3 Days, Oct. 8

Surgery of Hernia 3 Days, Oct. 11

Basic Electrocardiography One Week, Oct. 1

Board Review, Internal Medicine — Part I Sept. 10

Advances in Medicine One Week, Oct. 15

Advances in Surgery One Week, Dec. 10

Blood Vessel Surgery One Week, Oct. 22

Board of Surgery Review, Part I Two Weeks, Nov. 5

Board of Surgery Review, Part II. Two Weeks, Nov. 26
Fractures & Traumatic Surgery Two Weeks, Oct. 1

Information concerning numerous other continuation courses
available upon request.

TEACHING FACULTY:

Attending Staff of Cook County Hospital

ADDRESS:

REGISTRAR, 707 South Wood Street,

Chicago 12, Illinois

CALIFORNIA MEDICINE

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Each Phenaphen capsule contains:

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Phenacetin (3 gr.) 194 mg.

Phenobarbital ( 14 gr.) 16.2 mg.

Hyoscyamine sulfate 0.031 mg.

1. Meyers. G. B.: Ind. Med. & Surg. 26:3, 1957. 2. Murray,
R. J.: N. Y. St. J. Med. 53:1867, 1953.

Also available:

PHENAPHEN with CODEINE PHOSPHATE

14 GR. (16.2 mg.) Phenaphen No. 2

PHENAPHEN with CODEINE PHOSPHATE

'/a GR. (32.4 mg.) Phenaphen No. 3

PHENAPHEN with CODEINE PHOSPHATE

1 GR. (64.8 mg.) Phenaphen No. 4
Bottles of 100 and 500 capsules.

A. H. ROBINS CO., INC., RICHMOND 20, VIRGINIA

Making today’s medicines with integrity. . . seeking tomorrow’s with persistence.

REFERENCES AND REVIEWS

(Continued from Page 27)

tions compared to isoniazid-resistant, susceptible, and “no
organism" cases. In resections in patients with streptomycin-
resistant tubercle bacilli, the proportion of complications
was reduced using effective drugs, that is, kanamycin,
viomycin, and sulfisoxazole in the noncontaminated group.

Acute Pericarditis with Subsequent Clinical Rheuma-
toid Arthritis — L. A. Grossman et al. Arch. Intern.
Med. — Vol. 109:665 (June) 1962.

Acute pericarditis with effusion was observed in 3 pa-
tients. Each had a left pleural effusion. Sections of the
pericardium, pleura and lung did not reveal any specific
pathological lesion. Negative cultures for acid-fast bacteria,
fungi, and viruses were obtained from the exudates and

Your public relations problem has been
our prune consideration in collection
procedures during tivo generations of
ethical service to the Medical Profession.

THE DOCTORS BUSINESS BUREAU

Since 1916

FOUR OFFICES FOR YOUR CONVENIENCE:

821 Morket St., San Francisco 3 GArfield 1-0460

Latham Square Bldg., Oakland 12 GLencourt 1-8731

617 S. Olive St., Los Angeles 14 MAdison 7-1252

19 Pine Ave., Long Beach HEmlock 5-6315

excised tissues. The pericarditis heralded a clinical picture
of rheumatoid arthritis. The possibility of later manifesta-
tions of other collagen disorders exists.

* * *

Carisoprodol in the Treatment of Tetany — J. Jesserer.

Deutsch Med. Wschr. — Vol. 87:360 (Feb. 26) 1962.

Carisoprodol (Sanoma or Soma) is N-isopropyl-2-methyl-
2-propyl-l,3-propanediol dicarbamate. It is chemically re-
lated to meprobamate. In animal experiments it shows the
characteristics of a muscle relaxant. For this reason it has
been used to counteract muscle spasms. The author used it
in 11 patients, 8 of whom had idiopathic tetany and 3 had
postoperative insufficiency of the parthyroids. Tablets con-
taining 350 mg. of carisoprodol were given 2 to 4
times daily. These doses suppressed the tetanic muscle
spasms without producing undesirable side effects. In a
patient with hysterical pseudotetany the drug was without
effect. The author recommends that carisoprodol be tried in
other cases of tetany.

Syphilis Today and Its Consequences — F. R. Gomila, Jr.

J. Louisiana Med. Soc. — Vol. 114:82 (March) 1962.

The physician must recognize that syphilis remains a
danger and that methods of detection must be routinely
employed. The indiscriminate use of penicillin has masked
many early manifestations of syphilis — many times dooming
people to a later life of blindness, insanity, neurologic com-
plications, paresis, etc. A person should not be given peni-
cillin until the doctor, by various tests, has ruled out the
possibility of a lurking treponema pallidum. Many physi-
cians and dermatologists are thinking of syphilis as a rare
disease, but statistics have proven that syphilis definitely is
not dead. The problems in venereal disease control today
(Continued on Page 72)

When treatment for

PQT

is indicated

ANDKOE

ANDROGEN- THYROID -COMBINATION

T.M.

tablets

in tivo convenient dosage forms

ANDROID

Each yellow tablet contains:

Methyl Testosterone 2.5 mg.

Thyroid Ext. (1/6 gr.) 10 mg.

Glutamic Acid 50 mg.

Thiamine HCI 10 mg.

ANDROID-H.P.

(High Potency)

Each orange tablet contains:

Methyl Testosterone 5 mg.

Thyroid Ext. (1/2 gr.) 30 mg.

Glutamic Acid 50 mg.

Thiamine HCI 10 mg.

Indications: Impotence in male.

Average Dose : One tablet three times daily.

Available : Bottles of 100 and 500 at your pharmacy.

Caution : Not to be used when testosterone is contra-indicated.

Federal law prohibits dispensing without prescription.

1. Methyltestorone-Thyroid in Treating Impotence, A. S. Titeff, General
Practice, Vol. 25, No. 2, Feb., 1962, pp. 6-8.

2. Thyroid- Androgen Relations, L. Heilman, et al., The Jrl. of Clin. Endo-
crinology and Metabolism, August 1959.

Write for samples and literature.. .

( BRoV.Wfc THE BROWN PHARMACEUTICAL COMPANY

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CALIFORNIA MEDICINE

decreased
inflammation”
in dry, pruritic
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SENILE DERMATOSES
ATOPIC DERMATITIS
PSORIASIS
STASIS DERMATITIS
CONTACT DERMATITIS
LOCALIZED
NEURODERMATITIS

BENEFICIAL RESULTS were obtained with SARDO in the bath in 122 of 135 patients (90%)
with dry, itchy skin conditions, in most cases with beneficial effect "after the first bath.”
Dryness was allayed in all cases, and associated itching "either completely relieved or
greatly improved.” No irritation or sensitization was observed.

This new study corroborated others2'4 showing that SARDO helps re-establish the normal
physiologic lipid-aqueous skin balance.

Pleasant, easy-to-use SARDO releases millions of microfine water-dispersible globules* in
the bath. Bottles of 4, 8 and 16 oz. ©1962 *Patent pending t.m.

SARDO consists of oils and various esters of specially selected organic acids having a chain length of cl 4
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lipophilic phase. Fragrance consists of natural essential oils, isolates, and aromatic chemicals.

SAMPLES and literature available from . . .

SARDEAU, INC.

75 East 55th Street, New York 22, N. Y.

1. Borota, A., and Grinell, R.N.:

J. Amer. Geriatrics Soc., 10:413, 1962.

2. Spoor, H. J.: N.Y. State J.M. 58:3292, 1958.

3. Lubowe, I. I.: Western Med. 1:45, 1960.

4. Weissberg, G.: Clin. Med. 7:1161, 1960.

Advertising • JULY 1962

Second Oral Contraceptive
Reported 100 Per Cent Effective

A second oral contraceptive recently was reported
100 per cent effective among more than 500 women.

Two studies on the synthetic hormone, norethin-
drone, were reported in the May 5 Journal of the
American Medical Association.

No pregnacies occurred in either study group
when the pill was taken precisely as prescribed, one
pill a day for 20 days of each menstrual cycle.

Norethindrone, which produces many of the same
effects as the female sex hormone progesterone, is
closely related to norethynodrel, the first oral con-
traceptive to become available on a prescription
basis in this country. Norethynodrel also has proved
completely effective when taken strictly according to
schedule. Norethindrone, introduced in 1957, has
not been marketed as a contraceptive. Both drugs
inhibit ovulation.

In the first study, 364 women seen at a Mexico
City clinic were studied over a period of 32 months.

“No patient who followed the instructions faith-
fully became pregnant,” Drs. Edris Rice-Wray,
Miguel Schulz-Contreras, Irma Guerrero and Al-
berto Aranda-Rosell, Mexico City, said.

Only 10 discontinued the method because of un-
pleasant reactions, they said. Side effects were not
harmful, simply annoying, they said. This method,
they concluded, proved harmless and effective.

The second study took place in San Antonio,
Tex., among 210 women, 84 per cent of whom were
of Mexican extraction. Eighty per cent of the group
had used norethindrone for two years or more and
28 per cent for three years or more, according to
Joseph W. Goldzieher, M.D., Louis E. Moses, M.D.,
and Lucy T. Ellis, San Antonio.

“Since the inception of this study there has not
been a single unplanned pregnancy,” they said.

None of the study group stopped taking the pill
because of side effects, they said.

In both studies, pregnancies occurred after the
patients stopped taking the pill. There were no ab-
normalities in these offspring, they said.

Physician Population Boosted By 4,500

The physician population of the United States
and its possessions increased by about 4,500 in
1961, the American Medical Association reported
recently.

Medical licensure statistics for 1961, compiled
by the A.M.A.’s Council on Medical Education and
Hospitals, were published in the June 9 Journal of
the American Medical Association.

A total of 8,023 first licenses to practice medicine
and surgery were issued in 1961, the report showed.
Since approximately 3,500 physicians died, the phy-
sician population increased by about 4,500, com-
pared with a net gain of about 4,330 in 1960.

“significant hearing improvement’’
occurred with Arlidin in
32 of 75 patients with recent
onset hearing impairment
due to labyrinthine
artery ischemia.

Rubin, W. and Anderson, J. R.:

Angiology 9:256, 1958.

ARLIDIN IMPROVES HEARING1
ARLIDIN IMPROVES HEARING2
ARLIDIN IMPROVES HEARING3
ARLIDIN IMPROVES HEARING4

Arlidin is available in 6 mg. scored tablets,
and 5 mg. per cc. parenteral solution.

See PDR for packaging.
Protected by U.S. Patent Numbers: 2,661,372 and 2,661,373.

Of 8,714 applicants for licensure by written ex-
amination, 7,650 passed while 1,064 (12.2 per
cent) failed, the report showed. However, the rate
of failure in approved medical schools was 2.8 per
cent. Twenty-six approved schools had no failures
among their graduates.

The greatest number of graduates from any one
school to be examined was 214 from the University
of Tennessee College of Medicine, the report said.

Statistics also were reported on the Educational
Council for Foreign Medical Graduates, founded in
1957 to certify that foreign-trained physicians en-
tering the United States had an education equivalent
to that of graduates of approved medical schools
in this country.

The Council, which has held eight qualification
examinations for foreign medical graduates, said
the “net effect” of the ECFMG certification plan has
been not to restrict but rather to increase both the
number and the quality of foreign medical graduates
coming to the United States for graduate training
in hospitals.

In 1961, more than 3,600 foreign medical gradu-
ates were qualified directly from abroad by the
ECFMG, the council said. The number of foreign
medical graduates taking the ECFMG examination
abroad is now greater than the number taking it in
the United States, the Council said.

vascular insufficiency
of the labyrinth is an important
etiologic factor in sudden
perceptive deafness . . .
“vasodilators [Arlidin] are
of considerable value.’’

Wilmot, T. J. and Seymour, J. C.:
Lancet 1:1098, 1960.

early cases of sudden
perceptive deafness should be treated
by immediate stellate block
“supplemented by the most effective
vasodilator drug [Arlidin] . . .
energetic measures to
retain blood supply to the inner
ear are imperative.”

Wilmot, T. J.: J. Laryngology &

Otology 73:466, 1959.

Emotional Problems Rank Third
Among University Students

Emotional problems ranked third behind respira-
tory and skin diseases among university students,
a 10-year study showed recently.

The study, conducted at the University of Wis-
consin from 1949-59, was reported by Alfred S.
Evans, M.D., and Jeffrey Warren, B.S., Madison,
Wis., in the June Archives of Environmental Health,
published by the American Medical Association.

Respiratory infections, not including flu, “far out-
numbered” all other causes of illness recorded at
the university’s student clinic and infirmary, the
authors said.

Respiratory ills, skin eruptions, psychiatric prob-
lems and gastrointestinal upsets were termed the
“Big Four” among the 10 most common diagnoses
in the young adult student population.

The availability and low cost of counseling and
psychiatric services might be a factor in the relative
frequency of emotional problems seen at the student
health facilities, the authors said. Another factor is
the greater likelihood of emotional problems emerg-
ing in university students than in those in a more
stable working environment, they said.

The findings point up the need for psychiatrists
and dermatologists, at least on a consultant basis,
in university health departments, they said.

in impaired hearing,
tinnitus, vertigo . . .

when due to ischemia of the inner ear . . .

brand of nylidrin hydrochloride N.F.

Clinical benefit in approximately 50% of cases
of recent onset hearing loss treated with
adequate vasodilator and other supportive
therapy is also reported by Sheehy.

Sheehy, J. L.: Laryngoscope 70:885, 1960.

IMPORTANT: Before prescribing ARLIDIN the physician
should be thoroughly familiar with general directions
for its use including indications, dosage,
precautions and contraindication. Write for
complete detailed literature.

u. s. vitamin & pharmaceutical corporation

Arlington-Funk Labs., div. • 800 Second Ave., New York 17, N. Y.

"relief of symptoms is striking with Rautrax-N,,+

Rautrax-N decreases blood pressure for almost
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essential hypertension. Rautrax-N also offers a
new sense of relaxation and well-being in hyper-
tension complicated by anxiety and tension. And
in essential hypertension with edema and/or con-
gestive heart failure, Rautrax-N achieves diure-
sis of sodium and chloride with minimal effects
on potassium and other electrolytes.

Rautrax-N combines Raudixin (antihyperten-
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of hypertensive symptoms than produced by ei-
ther component alone. Rautrax-N is also flexi-
ble (may be prescribed in place of Raudixin or
Naturetin c K) and economical (only 1 or 2
tablets for maintenance in most patients).

Supply: Rautrax-N — capsule-shaped tablets provid-
ing 50 mg. Raudixin, 4 mg. Naturetin and 400 mg.
potassium chloride. Rautrax-N Modified — capsule-
shaped tablets providing 50 mg. Raudixin, 2 mg.
Naturetin and 400 mg. potassium chloride.

tHutchison J. C.: Current Therap. Res. 2:487 (Oct.) 1960.

For full information, see your Squibb Product Reference or Product Brief.

Rautrax-N’

Squibb Standardized Rauwolfia Serpentina Whole Root (Raudixin)
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CALIFORNIA MEDICINE

DIRECTORY

HOSPITALS • SANITARIUMS • REST HOMES

COMPTON FOUNDATION
HOSPITAL

FORMERLY COMPTON SANITARIUM

820 West Compton Boulevard
COMPTON, CALIFORNIA
NE 6-1185 NE 1-1148

MEMBER OF

American Hospital Association and
National Association of Private Psychiatric Hospitals

High Standards of Psychiatric Treatment
Serving the Los Angeles Area

G. Creswell Burns, M.D.
Medical Director
Helen Rislow Burns, M.D.
Assistant Medical Director

Fully Approved by Central Inspection Board of APA
Accredited by

Joint Commission on Accreditation of Hospitals

ALEXANDER SANITARIUM, Inc. located in the foothills of BELMONT, CALIFORNIA

Address Correspondence: MEDICAL DIRECTOR, Alexander Sanitarium, Inc., Belmont, California • LYtell 3-2143

The Alexander Sanitarium is a neuropsychiatric open hospi-
tal for treatment of emotional states, geriatric cases and alcohol-
ism. Treatments include hydrotherapy, electro and insulin
shock-therapy, psychotherapy and occupational therapy. Con-
ditional reflex treatment for alcoholism.

Occupational facilities consist of special occupational therapy
room, tennis court, billiards, badminton court, table tennis and
completely enclosed, heated, full-size swimming pool.

J. M. CRUIKSHANK, M.D., D.P.H., F.A.C.S., Medical Director
PSYCHIATRISTS: JOHN ALDEN. M.D., Chief of Staff: HEN-
DRIE GARTSHORE, M.D., Asst. Chief of Staff; P. P. POLIAK,
M.D., Asst. Chief of Staff; GEORGE KOLAWSKI, M.D.

A patient accepted for treatment may remain under the
supervision of his own physician if he so desires

AT HERRICK MEMORIAL HOSPITAL • 2001 DWIGHT WAY • BERKELEY 4, CALIFORNIA

A NEW HOSPITAL ATTACHED REHABILITATION CENTER

FOR PATIENTS HAVING

• Cardiovascular Accidents • Arthritis

• Spinal Cord Injuries • Industrial Injuries

• Amputations • Speech & Hearing Problems

• Congenital Deformities

THE CENTER OFFERS

• Physical & Occupational Therapy • Social Service

• Speech & Hearing Therapy • Hubbard Tank

• Inpatient Care • Self Care • Outpatient Care

THE REFERRING DOCTOR CONTINUES IN COMPLETE CHARGE OF HIS PATIENT

embership open to all members of the AMA)

P/1 P, i P

is a new chance at livingl

Advertising

JULY 1962

References and Reviews

(Continued from Page 56)

are (a) complacency on the part of everyone, thinking that
since World War II penicillin, has cured all syphilis, and
(b) failure of hospitals, institutions, prisons, private prac-
titioners, and clinicians to order a routne blood test on
each patient or inmate. The one thing that completely de-
feats the control of syphilis is the failure of physicians,
hospitals, institutions, all laboratories — both state and pri-
vate— to notify immediately the proper public health officials
each and every time they discover an early infectious case
of syphilis, so that the infected person may be interviewed
for sex contacts. It is only through applied epidemiology
that any chain of a syphilitic infection can be broken.

For topical treatment of DENUDED

<•”<* PAINFUL SKIN LESIONS

Anti-Pyrexol antiseptic ointment reduces pain, minimizes scarring:, aids
healing of burns, sunburn, scalds, lesions, wounds, and local inflamma-
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houses. 1. 5, 10 and 50 lb. tins. Time tested — professionally since 1921.
Active ingredients: Oils of spearmint, bay, wintergreen (syn.), sali-
cylic acid, lanolin, zinc oxide, phenol A&-X,
ortho-hydroxyphenyl-mercuric chloride .056%,
petrolatum, paraffin.

Anti-Pyrexol Benzocaine. Acutely anesthetic.

Contains Benzocaine 3%. 1, 5 and 10 lb. tins.

EASY SPREADING

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KIP, INC.- LOS ANGELES 21

Temporary Care of Mentally Defective Children on a

Pediatric Unit -S. Yudkin and .]. B. Burke. Lancet —

Vol. 1:633 (March 24) 1962.

A number of mentally defective children were admitted
to a pediatric unit during the summer months for a fort-
night each to relieve their families. Questionnaires showed
that the parents of other children on the ward did not
object. Low-grade defectives were less disturbed by the
separation than higher-grade defectives. The problems en-
countered are discussed.

Clinical Significance of Prolapse of Gastric Mucosa —

M. D. Custer, Jr., J. C. Hortenstine, and E. W. Lacy, Jr.

Ann. Surg. — Vol. 155:681 (May) 1962.

The clinical significance of prolapse of gastric mucosa has
been a matter of controversy since 1911. In recent years the
literature has shown a definite trend toward acceptance of
the lesion as an important cause of upper abdominal pain.
This study reports the results in 10 patients operated upon
for prolapse without other lesions. Excellent relief was
obtained in 7, fair in 3. The authors express preference for
gastric resection .over pyloroplasty.

s|; ❖ *

“Due Caution” and Radioiodine in Children — D. A.

Fisher and T. C. Panos. Amer. J. Dis. Child. — Vol.

103:729 (June) 1962.

A review of available pertinent data regarding harmful
genetic and somatic effects of radioiodine in children indi-
cates that the limiting dosage factor of diagnostic radio-
iodine in children is the potential radiation damage to
thyroid cells. Reliable radioiodine uptake studes are possible
in children with 0.05 to 0.2 fic I131/kg. of body weight.
Available information suggests that the radiation risk with
such doses is minimal.

©be (SHJteat

PROFESSIONAL LIABILITY INSURANCE

t&e doctor '& practice

Professional Protection Exclusively since 7899

SAN FRANCISCO OFFICE: Gordon C. Jones and John K. Galloway, Representatives
1518 Fifth Avenue, San Rafael Telephone 453-5143

Mailing Address: P. O. Box 1079, San Rafael
LOS ANGELES OFFICE: Gilbert G. Curry and Davis S. Spencer, Representatives
Room 109, 101 Vi East Huntington Drive, Arcadia Telephone MUrray 1-5077

Mailing Address: P. O. Box 543, Arcadia

CALIFORNIA MEDICINE

Carry it ...

Even a petite nurse can easily pick up and carry a Sanborn Visette® electrocardiograph
wherever it’s needed — in the office, on house calls, in the clinic or laboratory. Not much
bigger than a doctor’s bag, the Visette weighs only 18 pounds — with all accessories.

And as portable as it is, a Visette nevertheless equals any “office standard” ECG in recording
quality and accuracy. Every record is sharp, clean, permanent and — as you expect from
Sanborn Company — diagnostically accurate. Compactness and ruggedness for travel are
achieved by the practical means of modern miniaturized circuitry, not by sacrificing accuracy.

wherever
you need

If you prefer the greater versatility of two chart speeds, three recording sensitivities and
provision for recording and monitoring other phenomena, the Model 100 Viso-Cardiette is a
logical choice. And when these capabilities are
needed in a mobile instrument, the mobile cabinet
version (Model 100M) is designed to be easily
rolled to bedsides in hospital or clinic.

Regardless of which of these three instruments
you choose, each has a valuable and unique fea-
ture: Sanborn service. It lasts long after the sale
. . . from people who know your ECG and value
your satisfaction.

“ on-the-spot 99

cardiography

SANBORN COMPANY

MEDICAL DIVISION Waltham 54. Mass.

Glendale Branch Office 203 So. Verdugo Rd., Chapman 5-6761 and 5-6762
San Francisco Branch Office 2310 Irving St., Lombard 4-1900
San Diego Resident Representative 2212 El Cajon Blvd., Cypress 6-4735
Fresno Resident Representative 31 1 N. Fulton St., Amherst 8-7271

Advertising * AUGUST 1962

Facts About Nursing
Needs in California

Here are some facts about nursing and nursing
needs in California:

In 1950 California had a ratio of 353 registered
professional nurses in active practice per 100,000
population; by 1957 this ratio had declined to 269.

The ratio of all nurses (active and inactive) in
California in 1960 was estimated to be 450 per
100,000 population. The ratio varied from 209 per
100,000 population in the Imperial Valley area to
598 in the San Francisco-Oakland area. Of nurses
residing in California (estimate is about 70,670)
only about 60 per cent are in active practice.

Your public relations problem has been
our prime consideration in collection
procedures during two generations of
ethical service to the Medical Profession.

THE DOCTORS BUSINESS BUREAU

Since 1916

FOUR OFFICES FOR YOUR CONVENIENCE:

821 Market St., San Francisco 3 GArfield 1-0460

Latham Square Bldg., Oakland 12 GLencourt 1-8731

617 S. Olive St., Los Angeles 14 MAdison 7-1252

1? Pine Ave., Long Beach HEmlock 5-6315

COOK COUNTY

graduate school of medicine

CONTINUING EDUCATION COURSES
STARTING DATES— FALL, 1962
Surgical Technic, Two Weeks. ...Two Weeks, Sept. 10, Nov. 5

Surgery of Colon & Rectum One Week, Sept. 17

Surgery of Stomach & Duodenum One Week, Sept. 24

Vaginal Approach to Pelvic Surgery. One Week, Sept. 10

Gynecology, Office & Operative Two Weeks, Sept. 17

Obstetrics, General & Surgical Two Weeks, Oct. 8

Urology Two Weeks, Oct. 29

Proctoscopy & Sigmoidoscopy One Week, Sept. 10

General Practice Review One Week, Oct. 8

Gallbladder Surgery 3 Days, Oct. 8

Surgery of Hernia 3 Days, Oct. 11

Basic Electrocardiography One Week, Oct. 1

Board Review, Internal Medicine — Part I Sept. 10

Advances in Medicine One Week, Oct. 15

Advances in Surgery One Week, Dec. 10

Blood Vessel Surgery One Week, Oct. 22

Board of Surgery Review, Part I Two Weeks, Nov. 5

Board of Surgery Review, Part II Two Weeks, Nov. 26

Fractures & Traumatic Surgery Two Weeks, Oct. 1

Information concerning numerous other continuation courses
available upon request.

TEACHING FACULTY:

Attending Staff of Cook County Hospital
ADDRESS:

REGISTRAR, 707 South Wood Street,

Chicago 12, Illinois

California now prepares only about 25 per cent
of the nurses it uses. The remainder come from
other states and other countries.

In September 1961 there were 57 accredited
schools of nursing which prepared nurses for li-
censing as registered nurses. Of these 16 offered
baccalaureate programs, 20 offered associate degree
programs, and 21 offered diploma programs, of
which two now are admitting no additional students.

In 1960, 1,288 students were graduated from
basic nursing programs. Of these 280 were from
baccalaureate degree programs, 234 were associate
degree programs and 774 were from diploma pro-
grams.

To meet nursing needs in California in the future,
it is estimated that about 9,500 new registered
nurses will be needed each year. Assuming that
California will continue to attract approximately
4,400 nurses each year from other states and other
countries, it is estimated that California schools of
nursing will need to graduate about 5,100 students
per year. This is more than four times the number
now being graduated.

There are now 47 accredited schools of vocational
nursing in California. In 1961 these schools gradu-
ated 1,600 students.

Need for Nurses
In California

These factors are bringing about the need for
additional nursing services:

1. The rapidly increasing population in Califor-
nia (from 16,000,000 in 1962 to an estimated
25,000,000 plus in 1975).

2. The increase in the number of people using
hospitals and the frequency of such use.

3. The need for additional hospital beds to meet
increased demands.

4. The shift from long-term to short-term hospital
stay for patients with acute illnesses.

5. Wider health coverage for all age groups.

6. Changes of patterns of care in hospitals
(progressive care, team nursing, etc.)

7. New practices in the care of the mentally ill
(day-night services, mental health clinics, group
therapy, psychiatric wards in general hospitals) .

8. Needs of the chronically ill, and the rapidly
increasing population over 65 years of age.

9. Development of home care programs and
nursing homes.

10. Rising birth rate resulting in an increase in
maternal and child care activities.

11. Increase in the number of tuberculosis pa-
tients treated at home and the recently announced
goal of ultimately eradicating tuberculosis as a
public health problem.

CALIFORNIA MEDICINE

Heart Rate During Sleep
Studied By FM System

An FM radio system has enabled researchers to
study heart rate patterns of patients during a night
of undisturbed, uninterrupted sleep, it was reported
in the June 16 Journal of the American Medical
Association.

The success of the study indicates that the tech-
nique, known as radiotelemetry, will make it possi-
ble to gather information on bodily functions which
were previously difficult to observe, Drs. Gordon
K. Ira Jr. and Morton D. Bogdonoff, Durham, N. C.,
said.

“Though the situation of uninterrupted sleep
does not present many technical difficulties, the fact
that the observations were made without in any
way disturbing the subject suggests that the method
will have wide application,” they said.

The study revealed that the heart rate of a sleeper
decreases gradually during the course of the night
and eventually reaches a low point after which it
may increase gradually, the researchers reported.

However, they said, the heart rate of persons
with hyperthryroidism did not decline during sleep.
Pulse rates in these persons ranged from 108 to
118 beats per minute, which were not appreciably
lower than their pulse rates while awake, they said.

The study also revealed that there were some
periods of increased heart rate during the night
which were associated with body movements.

“Simultaneously recorded electroencephalograms
[records of brain activity] demonstrated that the
depth of sleep lightened at the time that body move-
ment and heart rate increases occurred,” they said.
“The plane of sleep, therefore, is fairly consistently
reflected by the contour of the heart-rate pattern :
when there is variability in heart rate, the plane of
sleep is light; when there is constancy in heart rate
level, the plane of sleep is deep.”

Prolonged and uninterrupted recordings of this
type have been difficult to obtain because of limits
imposed by recording equipment, the two physicians
said. Advances in electronic miniaturization have
led to the development of transistorized radio in-
struments which make it possible to signal informa-
tion without bulky recording equipment, they said.

A transmitter, the size of a package of cigarettes,
is used in the new technique, the authors explained.
The patient’s heart beat is picked up by leads at-
tached to his chest which are connected to the
transmitter worn in a wide belt, they said.

The transmitter, operating on a frequency allo-
cated by the Federal Communications Commission,
broadcasts an FM signal which is received on a
standard FM radio, they said. From the receiver,
the signal is fed into a tape recorder and then to
other machines for analyzing the data, they said.

The authors are affiliated with the department of
medicine Duke University Medical Center.

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REFERENCES

AND REVIEWS

Keloids and Barbiturate Coma — S. Blau, N. B. Kanof,
and H. B. Eiber, Arch. Derm. — Vol. 85:747 (June) 1962.
A strange formation of keloids is described in three
young women. These lesions followed the healing of trau-
matic skin erosions produced during the agitated phase of
suicidal barbiturate coma.

* ❖ ❖

Management of Fatigue: Physiological Approach — -
D. L. Shaw, M. A. Chesney, I. F. Tullis and H. P. K.
Agersborg, Amer. J. Med. Sci. — Vol. 243:758 (June)
1962.

The potassium and magnesium salts of aspartic acid
(aspartates) were administered to relieve chronic fatigue,
with and without associated somatic disease, in a blind
study of 163 subjects; normal and placebo controls and a
double blind cross-over trial were included. The subjective
response was positive in 86 per cent after active therapy, and
25 per cent after placebo. The over-all correlation between
the subjective response and the findings in objective meas-
urement of neuromuscular irritability was 88 per cent.

Tuberculosis in Man, Dog, and Cat — V. M. Hawthorne
and I. M. Lauder, Amer. Rev. Resp. Dis. — Vol. 85:858
(June) 1962.

Growths of Mycobacterium tuberculosis of human origin
were recovered, probably as commensals, from 8 of 70 ap-
parently healthy dogs and cats in contact with human
tuberculosis. Tuberculosis was found in 41 of 354 humans

in contact with 31 dogs dying of tuberculosis. This indicates
the same need to notify the Public Health Department of
a tuberculous animal as of a tuberculous human. The use
of BCG as a diagnostic test for tuberculosis in dogs and
cats was described and compared that of with purified
protein derivative (PPD), which was ineffective.

❖ ❖ ❖

Calcium Balance Made Easy — W. P. U. Jackson — Lancet
—Vol. 1:849 (April 21) 1962.

This review article considers the calcium balance in dif-
ferent circumstances, normal and pathological. The report
is illustrated by several simple diagrams; it also summarizes
the author's hypothesis of intestinal compensation for loss
of calcium in the urine.

Nonsuture Repair of Blood Vessels — J. E. Healey, Jr.,
R. L. Clark, H. S. Gallager, P. O'Neill, and K. S. Sheena,
Ann. Surg. — Vol. 155:817 (June) 1962.

A technique for nonsuture linear and circumferential re-
pair of blood vessels utilizing a plastic adhesive (Eastman
910) is described. A clamp (anastomat) specially designed
for rapid restoration of blood flow during circumferential
repairs is described in detail. The results of 170 vascular
repairs performed on animals are discussed. Only two fa-
talities occurred as a result of hemorrhage at the repair site.
The advantages, precautions in application, and disadvan-
tages of the method are presented.

* * *

Retinal Detachment and Glaucoma I — J. G. Sebestyen,
C. L. Schepens, and M. L. Rosenthal, Arch. Ophthal. —
Vol. 67:736 (June) 1962.

Retinal detachment was treated in 160 patients by scleral
buckling procedure, using a circling polyethylene tube in

(Continued on Page 30)

AT HERRICK MEMORIAL HOSPITAL • 2001 DWIGHT WAY • BERKELEY 4, CALIFORNIA

A NEW HOSPITAL ATTACHED REHABILITATION CENTER

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REFERENCES AND REVIEWS

(Continued from Page 24)

most cases. Pre- and postoperative gonioscopic and tono-
metric findings were described, and factors which influenced
postoperative elevation of ocular pressure were discussed.
The findings failed to show that glaucoma occurred in an
alarming number of instances as a result of the scleral
buckling operation with circling polyethylene tube.

* * #

Aminopeptidase in Elastotic Skin — J. Hasegawa, Arch.
Derm. — Vol. 85:720 (June) 1962.

Histochemical study of 10 punch biopsy specimens of
elastosis of skin showed localization of an aminopeptidase
in the areas of elastosis. Adsorption of the aminopeptidase
from the adjacent cellular structures could not be demon-
strated.

❖

Marginal Keratitis Following Muscle Surcery — J. S.
Nauheim, Arch. Ophthal. — Vol. 67:708 (June) 1962.

Ten cases of keratitis and corneal ulceration adjacent to
the site of previous eye muscle surgery were observed.
Lesions occurring between 5 and 19 days postoperatively
were healed within 3 to 28 days. Local antibiotics to pre-
vent secondary infection were advocated. Embarrassment
of local corneal circulation due to section of anterior ciliary
vessels and prolonged local conjunctival edema were postu-
lated as cause.

❖ ❖ ❖

Mortality Causes in General Surgery: A 30-Year Study
— C. B. Morton, II — Ann. Surg. — Vol. 155:991 (June)
1962.

During 30 years, 1928-1957 inclusive, 9,364 patients un-
derwent 9,734 major surgical operations performed by a
single surgeon in an ordinary general surgical practice.

There were 195 deaths, a patient mortality rate of 2.29 per
cent, an operation mortality rate of 1.75 per cent. Several
tabulations indicating the mortality by years, and classified
the deaths by regions, by operations, and by the pathologic
processes responsible for death.

❖ * *

Giant Pericardial Cyst — C. A. Ross and A. G. Ramos,
Amer. Rev. Resp. Dis. — Vol. 85:895 (June) 1962.

An unusual pericardial cyst sufficiently large to produce
dyspnea by compression of normal lung is described. The
cyst arose in the mediastinum and extended to both the
left and right hemithorax. It contained 3 liters of clear
fluid. Total excision by bilateral anterior thoracotomy gave
complete relief of symptoms.

❖ ❖ <c

Direct-Access Diagnostic Facilities in General Prac-
tice— T. S. Eimerl, Lancet — Vol. 1:851 (April 21) 1962.

The results of a survey of figures provided by the Min-
istry of Health for 1958 and 1960 are presented. It is shown
that with 21,000 family doctors freely available to 45 million
people only 6 per cent of all patients referred for routine
pathology are sent via G.P.’s, only 9 per cent of all radi-
ology is performed at the request of G.P.’s. In teaching hos-
pitals only 1 in 50 of all investigators in pathology and only
1 in 80 of all investigators in radiology are requested by
family doctors. Lessons drawn from this imbalance suggest
that 13 years after the inception of the National Health Serv-
ice, family doctors do not have all the facilities of direct-
access diagnostic investigation essential to good family
doctoring. Suggestions are offered regarding the functional
design and the purpose of a hospital which offers a full
range of care. A comparison is drawn between medical prac-
tice in the United Kingdom and medical practice in Hol-
land and in the Scandinavian countries.

CALIFORNIA MEDICINE

^ ^MEDICI

OFFICIAL JOURNAL OF THE CALIFORNIA MEDICAL ASSOCIATION
© 1 962, by the California Medical Association

Volume 97 AUGUST 1962 Number 2

Correctable Cardiac Failure

ARTHUR SELZER, M.D., and FRANK GERBODE, M.D., San Francisco

In spite of dramatic advances in the treatment
of hypertensive diseases, the term “curable” hyper-
tension can only be applied to the relatively small
group of cases in which the cause of hypertension
can be removed surgically, such as coarctation of
the aorta, pressor-substance producing tumors, or
correctable renal and renal-vascular disorders. Other
forms of hypertension can at best be controlled
by continuous therapy. An analogous situation has
been created by recent surgical strides in the treat-
ment of chronic cardiac failure, for in a growing
number of conditions the cause of failure can be
removed surgically, reversing otherwise intractable
heart failure.

There are few concepts in clinical medicine that
match cardiac failure with regard to the con-
troversy and confusion surrounding its clinical,
physiological and metabolic definition. The intro-
duction of modern, precise physiological methods
into clinical medicine helped to clarify many points
but at the same time brought into focus other un-
answered questions. However, two concepts can be
considered as generally accepted: (a) the two ven-
tricles can fail and recover from failure inde-
pendently of each other; (b) heart failure is
usually caused by increased work — “overload” of
a cardiac ventricle.

The work of the heart is expressed in physiological
terms as a product of the quantity of blood ejected

From the Institute of Medical Sciences, Presbyterian Medical Center,
San Francisco 15.

Presented at the Eighth Annual Symposium on Cardiovascular Dis-
eases of the Monterey County Heart Association, Fort Ord, January 20,
1962.

Submitted March 5, 1962.

• The concept of reversible cardiac failure lias
hitherto been applicable mostly to rare instances
of acute afflictions of the myocardium wherein
cardiac compensation returns with the healing
of the process. Recent strides in cardiac surgery
have brought into focus a wide variety of condi-
tions where operative removal of the cause of
heart failure can successfully restore compen-
sation.

The concept of increased work of the heart —
cardiac overload — is presented and classified
with special reference to those forms where sur-
gical removal of the cause of the overload is
possible.

Now, since surgical treatment of a patient in
functional class IV need no longer entail risk
of prohibitive mortality, a careful search is in-
dicated in patients in a state of chronic cardiac
failure, particularly in the younger age group,
for a correctable factor or factors.

into the arterial system and the pressure against
which it is expelled. It follows that overloading of
a ventricle can occur when the output is excessive
or the pressure elevated. Physiological increase in
cardiac work occurs during exercise, when cardiac
output rises; during stress and excitement when
pressure is increased. Pathological cardiac over-
work occurs when pressure overload or volume
overload occurs continuously rather than inter-
mittently. Such pathological overload stimulates a
compensatory increase in muscle mass — cardiac
hypertrophy — which can, for variable lengths of
time, maintain an adequate circulation in spite of
its overloading. Eventually the hypertrophied ven-
tricle becomes inefficient and the symptom complex

VOL. 97. NO. 2 • AUGUST 1962

Figure 1. — Diagrams of the circulation: top, normal;
middle, left ventricular failure due to hypertensive
overload; bottom, that due to myocardial scars. The
top drawing presents a diagram of a normal circula-
tory system by indicating pressures in the various regions
and a normal stroke volume of 75 cc. per heat. The mid-
dle drawing presents left ventricular failure due to abso-
lute systolic overload of chronic hypertension. Left ven-
tricular hypertrophy is shown and failure of that ventricle
indicated by an elevation of the diastolic pressure to 25
mm. and by reduced stroke volume to 50 cc. per heat.
Left ventricular diastolic hypertension leads to elevation
of left atrial pressure and passive pulmonary hyperten-
sion. However, the right ventricle, though overloaded, is
still competent. The bottom drawing presents left ven-
tricular failure due to relative left ventricular overload
from chronic scarring of that ventricle after myocardial
infarction. Left ventricular hypertrophy is also present
here and its hemodynamic sequelae are identical with
those shown above.

of chronic cardiac failure develops. A variety of
cardiac diseases exemplify conditions associated
with chronic ventricular overload. Hypertension and
valvular stenosis produce pressure overload; volume
overload is brought about by valvular regurgitation,
shunting lesions and hypercirculatory states. Pres-
sure overload, often referred to as systolic overload,
causes concentric ventricular hypertrophy unas-
sociated with dilatation until later, during the stage
of decompensation. Volume overload, as diastolic
overload, leads to early development of cardiac
dilatation (eccentric ventricular hypertrophy).

The concept of chronic overloading of the circula-
tion is applicable to many but not all forms of
cardiac failure. The most important form of chronic
cardiac failure in which the work of the heart
appears not to be increased is that occurring in the
late stage of ischemic heart disease (“arterio-
sclerotic heart disease”). Yet in such cases chronic
failure is likely to occur only if a significant portion
of the left ventricular myocardium is replaced by
functionally inactive scar tissue. It follows that the
normal cardiac work has to be performed by a con-
siderably reduced number of muscle fibers and that
therefore the work per muscle fiber is increased.

One is thus justified in accepting this condition as
a variant of the chronic overload and in using
the term “relative cardiac overload.”

A comparison of “absolute” and “relative” over-
loading of the left ventricle is presented in diagram-
matic form in Figure 1.

There are, however, conditions in which the
concept of overloading of a cardiac ventricle as
a cause of cardiac failure does not seem to be ap-
plicable. Among them are the various inflammatory,
degenerative or toxic conditions affecting cardiac
performance, in which all or most muscle fibers are
uniformly affected. Many of these afflictions are
acute and constitute truly reversible cardiac failure:
the circulatory derangement returns to normal with
the healing of the myocardial lesion.

When can chronic cardiac failure be considered
reversible? The mere disappearance of clinical
manifestations of heart failure does not provide
evidence of reversibility. Studies in our laboratory1
have demonstrated that patients with various forms
of cardiac failure may become totally asymptomatic
in response to therapy and yet almost always show
abnormal hemodynamic findings, demonstrating
that they are merely in a state of controlled heart
failure. The only real examples of reversibility of
chronic cardiac failure are those in which chronic
overload responsible for failure can be totally or
partially eliminated. It is obvious that only absolute
cardiac overload can be eliminated: relative over-
load, as stated above, is caused by reduction of
the number of contracting myocardial units and
is not correctable.

A simple example of the elimination of cardiac
overload is the treatment of hyperthyroidism or
anemia. Both of these conditions lead to a hyper-
circulatory state but seldom of themselves lead to
chronic cardiac failure, acting mostly as a contribu-
tory factor in combined cardiac lesions. Therefore,
it is quite rare to find spectacular elimination of
chronic heart failure by the correction of these
states. It is by surgical elimination of overload that
dramatic elimination of advanced heart failure and
a complete rehabilitation of a chronic “cardiac
cripple” can be brought about. The following is a
brief discussion of the more important forms of
surgically correctable cardiac overload.

Left ventricular failure

Systolic overload of the left ventricle. This is
responsible for heart failure after prolonged systolic
left ventricular hypertension, which in turn may be
caused by either arterial hypertension or by aortic
stenosis. Chronic cardiac failure from arterial hyper-
tension is seldom reversible unless a surgically cur-
able form of hypertension exists. The fact that
medical treatment of hypertension usually does not

CALIFORNIA MEDICINE

Figure 2. — Anteroposterior roentgenogram of a patient with severe mitral regurgitation: left, before; right, after
mitral valvular repair.

reverse cardiac failure resulting from it is probably
related to the widespread vascular deterioration
which is usually present by the time chronic cardiac
failure has developed.

On the other hand, aortic stenosis may lead to
intractable cardiac failure which is quickly and
dramatically reversed if the obstruction can he
entirely relieved, therefore restoring normal left
ventricular systolic pressure.

Diastolic overload of the left ventricle. The two
common conditions with increased cardiac work of
this type are patent ductus arteriosus and aortic
regurgitation. In both, the left ventricle ejects an
excessive amount of blood. In both, hypertrophy
associated with early dilatation of that chamber
occurs. Left ventricular overload of this type is
relatively well tolerated, and it is not unusual to
find an extreme degree of cardiomegaly with little
or no disability. Cardiac failure occurs late but is
often then unrelenting, and refractory to therapy,
unless surgical treatment can eliminate the overload
altogether. The dramatic reversal of cardiac failure
and reduction in cardiac size in cases of this cate-
gory in which surgical treatment was successful are
among the most spectacular results in the field of
cardiac surgery.

Combined ventricular failure

Left ventricular failure from any cause produces
passive pulmonary hypertension, as shown in Figure
1, which leads to systolic overload of the right
ventricle. This is occasionally exaggerated by the
occurrence of pulmonary arteriolar spasm or
pulmonary vascular disease developing secondarily
to passive pulmonary hypertension. Thus it is well
known that left ventricular failure is the commonest

cause of right ventricular failure which eventually
results from right sided overload. However, two
conditions are known to cause initial overload of
both ventricles: mitral regurgitation and ventricular
septal defect. Mitral regurgitation produces diastolic
overload of the left ventricle by necessitating the
ejection of large quantities of blood into the atrium
in addition to that into the aorta.

Recent studies have shown that as much as 75
per cent of the total output may be regurgitated into
the atrium. However, in contrast to aortic regur-
gitation and patent ductus, mitral regurgitation
causes left atrial hypertension. Consequently the
resulting right ventricular overload occurs before
the onset of left ventricular failure. Ventricular
septal defect associated with a sizable left-to-right
shunt leads to increased output of both ventricles,
causing diastolic overloading of both sides. In both
ventricular septal defect and mitral regurgitation,
left ventricular overload and failure usually pre-
dominate, hut pulmonary hypertension may progress
to a point where right ventricular hypertrophy and
failure come into the foreground. Surgical therapy
may completely eliminate the overload and reverse
cardiac hypertrophy and failure. Figure 2 illustrates
the regression of cardiomegaly in a patient who
before surgical treatment was totally disabled by
combined right and left heart failure due to mitral
regurgitation and who became virtually asympto-
matic after successful repair of the valve lesion.

Right ventricular failure

Right ventricular failure is the result of right
ventricular overload under conditions analogous
to events in the left heart referred to above. How-
ever, only absolute right ventricular overload is

VOL. 97. NO. 2 • AUGUST 1962

of importance, since involvement of the right
ventricular myocardium leading to its relative over-
load is not known to be of major importance.
Again, two forms of right sided overload can occur:
pressure and volume.

Systolic overload of the right ventricle. In-
creased work of the right ventricle here is caused
by elevated systolic pressure in it, which may be
due to abnormally high resistance at the pulmonary
valve or beyond it; pulmonary stenosis and pul-
monary hypertension. Pulmonary stenosis is usually
well tolerated when mild or moderate in severity.
Severe pulmonary stenosis may lead to intractable
right ventricular failure, which is occasionally com-
plicated by the opening of the incompletely sealed
foramen ovale, resulting in significant anoxemia
or even gross cyanosis. Both failure and anoxemia
are reversible by surgical treatment. Pulmonary
hypertension occurs in a variety of conditions and
has many causes. In general, pulmonary hyperten-
sion falls into three categories: increased resistance
within the pulmonary vascular tree, increased re-
sistance beyond the pulmonary venous system
(“passive pulmonary hypertension”), and the com-
bination of both. The first type is, as a rule,
irreversible. The other two may or may not be
reversible; passive pulmonary hypertension may
be caused by left ventricular failure or by mitral
valve disease. The former has already been dis-
cussed: its reversibility depends on whether or not
the left sided lesion is correctable. Mitral stenosis
is the commonest and the best known cause of
reversible passive pulmonary hypertension. It
should be noted, however, that uncomplicated mitral
stenosis, even severe, seldom causes severe enough
pulmonary hypertension to lead to chronic right
ventricular failure, which if present is almost
always due to the development of secondary pul-
monary vascular reactions. Thus, in some 15 per
cent of cases of mitral stenosis, pulmonary hyper-
tension of a combined type develops, which is then
apt to cause chronic right ventricular failure. Two
points are noteworthy in connection with mitral
stenosis: pulmonary hypertension complicating

mitral stenosis may become severe enough to
dominate the clinical picture and obliterate the
clinical landmarks identifying mitral stenosis. Seri-
ous errors have been made on occasion by mis-
taking such cases of mitral stenosis for irreversible
primary pulmonary hypertension. Furthermore,
surgical correction of mitral stenosis abolishes not
only passive pulmonary hypertension but leads to
gradual regression of pulmonary vascular disease,
thus further accentuating beneficial effects of the
operation.2

Diastolic overload of the right ventricle is ex-
emplified by the atrial septal defect. In the presence

of an interatrial communication the lower resistance
to diastolic filling of the right ventricle causes large
left-to-right shunt with the volume load of the right
ventricle as high as four times that of the left.
Curiously, severe volume overload of the right
ventricle is very well tolerated and cardiac failure
from an uncomplicated atrial septal defect is virtu-
ally unknown in children and adolescents. In adults,
however, the chronic increase in pulmonary blood
flow often leads to secondary pulmonary vascular
disease and pulmonary hypertension. When that
happens, chronic right ventricular failure may
develop. It should be emphasized that unlike mitral
stenosis, pulmonary hypertension in atrial septal
defect has a point of no return, beyond which
surgical treatment is ineffective and may even be
harmful. Thus there is good justification for the
performance of surgical repair of atrial septal de-
fect in asymptomatic patients, provided facilities
are available for the performance of such opera-
tions with a minimum mortality.

As stated, the foregoing discussion dealt only
with the more common forms of cardiac overload
leading to chronic cardiac failure. There are many
other rarer forms of heart disease, some of which
are reversible by surgical treatment, some not. It
is particularly noteworthy that cardiac lesions fre-
quently occur in combinations. Both congenital
heart disease and rheumatic heart disease, the two
principal etiologic causes of correctable cardiac
lesions, show a tendency to affect more than one
area of the heart. The hemodynamic consequences
of combined lesions are usually additive and physio-
logical studies often can unravel the respective
contribution of the component lesions to cardiac
disability. It is of considerable importance to dis-
tinguish between the principal overloading lesion
and the lesser contributory factors, for to attempt
surgical repair of all the anatomical defects might
seriously and unnecessarily increase the risk. It is
necessary to appreciate the fact that, if chronic
cardiac failure develops because the heart is over-
loaded by 150 per cent over its normal work, a
complete reversal of failure may result by the re-
duction of the overload to 25 or 50 per cent. A
partial correction, wherein one lesion is repaired
and another left untreated, is indicated when the
total repair seriously magnifies the surgical hazard.
Such situations develop frequently in the treatment
of combined mitral and aortic lesions where the
mitral disease predominates, or in atrial septal
defects complicated by one or two transposed
pulmonary veins, to name two examples.

Among unusual problems associated with surgical
treatment of cardiac failure, two deserve comment.
The first, constrictive pericarditis, does not cause
heart failure in the ordinary sense, but rather
congestive phenomena masquerading as heart

CALIFORNIA MEDICINE

Figure 3. — Anteroposterior roentgenogram of a pa-
tient with a large aneurysm of the left ventricle.

failure. Surgical treatment of constrictive peri-
carditis, the oldest operation in the field of car-
diac surgery, is probably performed less often
than it ought to be because less typical forms of
it may be overlooked. The classical picture of con-
gestive “failure” with a small and quiet heart is not
always present, and the differentiation between
constrictive pericarditis and conventional forms of
cardiac failure may be very difficult. The second
problem concerns ventricular aneurysms. As the
resection of aneurysms of the heart becomes tech-
nically possible and relatively safe, it is often
tempting to consider the mere presence of such
aneurysms as indication for operation. Figure 3 is
a roentgenogram, taken in 1945, showing a large
aneurysm of the left ventricle. The patient now is
well and virtually asymptomatic. Uidike aneurysms
of the great vessels, healed aneurysms virtually
never rupture. Physiologically they resemble mitral
regurgitation in that during systole the left ventricle
has to eject blood into the aorta and also fill the
aneurysmal sac, which overloads that cardiac cham-
ber. As in mitral regurgitation, such left ventricular
overload may be small, causing no major circula-
tory derangement, or large, leading to heart failure.
Thus if chronic failure is present in a case of
ventricular aneurysm and if the systolic expansion
of the aneurysm indicates loss of large volume of
blood, surgical treatment is indicated and often
leads to spectacular improvement.

What is the role of the practicing physician
in relation to the problem of surgical treatment
of cardiac failure? Using again the example of

hypertension, it is now generally recognized that
every case of severe hypertension, particularly in
a younger person, should be investigated with re-
gard to the possibility of a curable form of hyper-
tension. A similar attitude is justified in dealing
with chronic cardiac failure. Only a high index of
suspicion regarding reversibility of chronic cardiac
failure will bring a satisfactory yield of surgically
correctable cases. It might seem, superficially, that
such cases are easy enough to recognize that they
should present no diagnostic problem. While this
is true for a typical case of mitral stenosis, aortic
stenosis or patent ductus arteriosus, there are many
instances in which the correct diagnosis is exceed-
ingly difficult to make and may require the most
complex laboratory procedures. It is well to re-
member that the very presence of cardiac failure
or of the complications that enhance failure, such
as pulmonary hypertension, brings into the picture
atypical and confusing clinical features. It has
already been mentioned that pulmonary hyper-
tension complicating mitral stenosis often suggests
the erroneous diagnosis of primary pulmonary
hypertension. Pulmonary hypertension tends to
obliterate the characteristic murmurs of patent
ductus arteriosus and ventricular septal defect.
Cardiac failure may reduce the murmur of aortic
stenosis to a seemingly inconsequential systolic
murmur. Severe cardiac failure may lower the
wide pulse pressure of aortic regurgitation to a
point where it is no longer suspected as being the
principal cause of the cardiac overload. Apical
systolic murmurs are exceedingly common in any
form of left ventricular failure and occasionally it
is difficult to decide whether mitral insufficiency is
the cause or the effect of cardiac failure.

In selecting patients with cardiac failure for sur-
gical treatment, it is essential that a comprehensive
diagnostic evaluation be made. This includes not
only an analysis of the hemodynamic factors lead-
ing to cardiac overload but a search for such com-
plicating factors as coronary artery disease, which,
if demonstrated in the coronary angiogram, would
make an operation inadvisable. The risk of operat-
ing upon properly selected patients in chronic
failure is higher than average, but not prohibitive
in the hands of a team with proper experience and
facilities to handle such cases.

Presbyterian Medical Center, Clay and Webster Streets, San Fran-
cisco 15 ( Selzer) .

REFERENCES

1. Selzer, A., and McCaughey, D. J.: Hemodynamic pat-
terns in chronic cardiac failure, Am. J. Med., 28:337, 1960.

2. Selzer, A., and Malmborg, R. 0.: Some factors in-
fluencing pulmonary vascular resistance in mitral valvular
disease, Anter. J. Med., 32:532, 1962.

VOL. 97, NO. 2 • AUGUST 1962

Ammoniacal Dermatitis

Clinical Observations on an Efficacious, Economical and
Neglected Treatment

WILLIAM K. FRIEND, M.D., Santa Ana

In spite of observations and detailed studies ex-
tending for more than fifty years, ammoniacal
diaper rash remains one of the most common skin
disorders encountered in pediatric practice. Al-
though mild cases respond to the usual simple
measures, some become quite severe, with ulceration
and secondary bacterial and fungal infection which
may be resistant to extremely energetic therapeutic
measures. It is the purpose of this paper to call
attention to a simple and effective method of man-
agement first described by Stephens and coworkers9
in 1952, and to outline the experience of a group of
pediatricians with it.

The characteristic erythematous, vesicular, papu-
lar and ulcerated forms of the skin lesions occurring
in the diaper area in association with ammonia in
the diaper have been well described by Jacquet,4
Adamson,1 Brenneman2 and Cooke.3 The observa-
tion by Cooke in 1929 that the primary cause of the
skin lesions was ammonia that was formed in the
diaper by the growth and activity of the organism
Bacterium ammoniagenes led to a rational therapeu-
tic approach. Cooke found this organism primarily
present in the feces and infrequently in the urine of
the affected infants. An alkaline medium is favorable
to growth of this bacterium and the organisms have
been observed to grow readily in a diaper that has
remained in contact with the skin for several hours
after urination.

Many products have been used to sterilize diapers
in order to break the bacterial metabolic chain and
thus to prevent formation of ammonia. Most of
them have been found to be deficient in one way
or another. Mercury compounds were effective but
were abandoned because of their decided toxicity.
Boracic acid was found to be potentially harmful
and was considerably less effective. More recently,
the quartinary ammonia compounds have been used.
These compounds, although nontoxic and frequently
effective under ideal conditions, have certain physi-
cal and chemical limitations. Even small residual
amounts of soap, detergent, organic materials, or
certain ingredients of hard waters such as calcium

Submitted March 5, 1962.

• Several pediatricians in one community began
instructing mothers of infants with ammoniacal
diaper rash to use o-benzvl-p-chlorophenol
(OBPC) in laundering diapers. This simple,
previously reported item of management was
prescribed in 87 cases of ammoniacal rash. In
almost all uncomplicated cases the rash cleared
in an average of four days; when complicated
by Staphylococcus aureus or Monilia albicans
infection, clearing took a few days longer. The
few cases of less than satisfactory results were
attributable to improper use of the chemical.

Several of the mothers had mild irritation of
the hands from use of OBPC.

and magnesium ions left in the diaper will rapidly
diminish the effectiveness of these compounds. It
has been demonstrated that a hardness of 150 parts
of these ingredients per million in the water used in
laundering diapers will reduce bactericidal activity
by about 70 per cent.1 Many geographical areas in
California have metropolitan water of approximately
170 parts per million, while well water in some
places has a content of 300 parts per million.

Recently it was observed at a hospital in Orange
County that none of the babies on the pediatric serv-
ice had ammonia diaper rash, and there was no
odor of ammonia in the diaper pail. It was further
noted that a residual rinse containing o-benzyl-p-
chlorophenol (OBPC) was used in laundering the
diapers. Stephens,9 in 1952, published an excellent
article on this use of the chemical, but for some
reason, although it is widely used by commercial
laundries and diaper services, it has never been
made available for use in individual home laundries.
A supply of OBPC was obtained and use of it in the
laundering of diapers was recommended by a group
of pediatricians, the material having been found to
sterilize diapers and, when impregnated into the
diapers in a final rinse, to leach out in urine to form
a bactericidal solution effective against Staphylo-
coccus aureus, Monilia albicans and Bacterium
ammoniagenes. The effectiveness of OBPC is not
decreased by the use of hard water, which may even
enhance its action, or by soaps or other residues.5

CALIFORNIA MEDICINE

TABLE 1. — Results of Laundering Diapers with Solution

of OBPC in Cases of Ammoniacal Diaper Rash

Results

Cause of Lesions

No. Cases Good Fair

Poor

Ammonia

Ammonia with secondary Monilia (proven by culture)

Ammonia with secondary Staphylococcus (proven by culture)

71 67 2*

9 7 1 (7 days)

7 6 1 (10 days)

1(2 weeks)
0

’OBPC was not used properly.

PRESENT STUDY

Our investigations were mainly in children with
severe ammoniacal dermatitis that had not responded
to the usual method of management. The rashes were
frequently complicated by ulcerative lesions or by
superimposed infection (confirmed by culture).
The mothers of children were instructed to use
OBPC* in such a way that the final rinse for diapers
was a solution of 1 part of the chemical in 2,500
parts water. In a high proportion of cases the lesions
cleared promptly (Table 1).

Uncomplicated ammoniacal dermatitis cleared
within an average of four days. Cases in which there
was superimposed Staphylococcus aureus responded
within an average of six days: and those with Moni-
lia albicans infection responded within an average
of seven days.

Stephens9 reported 250 cases of a similar nature
with completely satisfactory results; and in an ad-
ditional 1,500 cases, in which the material was used
prophylactically, none of the patients had ammonia-
cal dermatitis.

Several of the mothers reported mild irritation of
their hands when using the rinse solution. Otherwise
no adverse effects were noted. As the concentrate
OBPC is a strong skin irritant, it must be kept out

* Commercially available as Diaper Safe.

of reach of children.8 In rabbits the lethal dose by
mouth is 1.5 gm. per kg. of body weight.5 When a
solution of 1 :300 was applied to the skin of rabbits,
no evidence of absorption was observed.5

1125 East 17th Street, Santa Ana.

REFERENCES

1. Adamson, H. C.: On eruption of the napkins region
l’Enfantes, Brit. J. Dis. Child., 5:13, 1908.

2. Brenneman, J.: The ulcerated meatus in the circum-
cised child, Am. J. Dis. Child., 21:38, 1921.

3. Kettering Lab. Bulletin, Cincinnati, June 1948. Sup-
plied by R. Emmet Kelly, Medical Director, Monsanto
Chemical Co., St. Louis, February 1960.

4. Cooke, J. V.: (A) The etiology and treatment of am-
monia dermatitis of the gluteal region of infants. Am. J.
Dis. Child., 22:481, 1921. (B) Dermatitis of diaper region
in infants, Arch. Derm, and Syph., 14:539, 1926.

5. Jacquet, L.: Traite des Maladies de l'Enfante, Paris,
1905, Grancher et Camby, Vol. 4, p. 714.

6. Kozinn, T., Burchell, M. A.: “Diaper rash,” a diagnos-
tic anachronism, J. Ped., 59:75-80, July 1961.

7. Layton Sof -Water Service, Personal Communication,
Santa Ana, March, 1961.

8. Monsanto Chemical Co., Letter from E. P. Wheeler,
Assistant Director, Medical Dept., to Orange County Poison
Information Center, March 1957.

9. Stephens, L. J.: o-Benzyl-p-Chlorophenol in the pre-
vention and treatment of ammonia dermatitis, J. Pediat.,
750, June 1952.

10. Tobin, L. : Studies on the effects of three commercial
diaper sanitizers on two tests organisms, B. Ammoniagenes
and M. Aureus, Unpublished Observations by Scientific
Assoc., St. Louis, Mo., Sept. 24, 1951.

VOL. 97

NO. 2

AUGUST 1962

What Scope Health Insurance?

EDWIN F. DAILY, M.D., New York

Vice-President, Health Insurance Plan of Greater New York

Health Insurance Plan of Greater New York
(hip) has 14 years’ experience in providing what
we consider a broad scope of medical care for in-
sured men, women and children in a predominantly
urban area. The number currently served is 637,000.

“Broad scope” and “comprehensive coverage”
are vague terms and require definition by each per-
son using them. In hip where medical care is
provided by 31 medical groups, the insured persons
prepay and are entitled to any needed medical care,
carried out at home, in a physician’s office or in a
general hospital, by the following types of physi-
cians in each medical group: family physicians, in-
ternists, pediatricians, obstetricians-gynecologists,
general surgeons, orthopedists, ophthalmologists,
otolaryngologists, radiologists, urologists, dermatol-
ogists, allergists, neurologists and pathologists. Al-
though each medical group has a psychiatrist, we
provide only diagnostic and consultation services
by these specialists.

In addition to these services provided by each
medical group, the groups collectively allocate 96
cents per enrollee per year to a Special Services
Fund. This fund pays the full cost for unlimited
visiting nurse service, ambulance service and diag-
nosis and treatment by a wide variety of special
consultants serving all medical groups. These special
consultants are in fields such as cardiac and thoracic
surgery, surgery of the middle ear, scoliosis sur-
gery, reconstructive hand surgery, oral surgery,
physical medicine and exchange transfusion. This
fund also pays the entire cost of a great many
of the more unusual laboratory tests that the aver-
age clinical laboratory is not equipped to per-
form. The cost of cobalt therapy and of second
opinion-consultations for serious conditions is also
paid for by this fund.

All of these services are provided without any
requirement that there be a waiting period between
joining the plan and receiving services for pre-
existing conditions or pregnancy, without any
charge above the premiums paid for any income
group, except for an optional fee of $2.00 for home
calls late at night. All immunization agents are pro-
vided without charge and injectable drugs given in
the office or at home are provided at cost.

Presented at the California Medical Association Annual Conference
of County Society Officers, February 17, 1962.

Submitted March 26, 1962.

The average number of services provided by the
physicians each year per insured person is cur-
rently 4.7. A service is defined as a face-to-face
meeting of doctor and patient (except for radiology,
where the definition is a patient contact with the
Radiology Department on a single day). The highest
utilization rate is in the first year of life, 13.8
services per year; and the lowest for the ages 15
to 24. 3.6 per year. For enrollees over 70 the rate
is 7.6 medical services per year. Eighty per cent of
all medical services are provided in the office, 12
per cent in hospitals and 8 per cent in patients’
homes. The proportions of medical services provided
by the various types of physicians are as follows:

Family physicians and

Per

Cent

Ophthalmologists ....

Per
Cent
.... 3.6

Internists

. 49.3

Orthopedists

.... 3.4

Pediatricians

11.5

Otolaryngologists ....

.... 2.6

Obstetricians.

Dermatologists

.... 2.6

gynecologists

. 7.4

Urologists

.... 1.6

Radiologists

. 6.8

Neuro-psychiatrists ..

.... 0.6

General surgeons

5.3

Other (except

Allergists

. 5.0

Pathologists)

.... 0.3

Laboratory tests for office patients average 2.73 per enrollee
per year.

The average premium income currently received
per insured person for the above services is ap-
proximately $42.60 per year. In 1961 over 90 per
cent of the HIP premium income was paid to the
medical groups.

Do people wish this scope of service and can
they afford to pay the cost of providing it?

I see many officials of organized labor (and most
health insurance in New York today is obtained
through union negotiations with employers) and
practically all of these leaders in recent years
wanted to buy at least the coverage provided by
hip. Many have expressed a wish to have dental
and drug coverage also.

The union officials in our area are insistent that
there be no means tests and that all income levels
in the unions have the same premium and the same
medical care benefits. They consider it equally im-
portant that there be no charges to the patients for
any medical care provided under the Plan — that is,
the premium must pay all the costs.

Can they afford it? Many unions in New York
City with members who are the lowest paid people
in the labor field have successfully negotiated with

CALIFORNIA MEDICINE

the employers for both HIP medical care and Blue
Cross hospital coverage.

When there are welfare funds or when employees
and employers split the cost of medical and hospital
coverage, the cost of coverage as extensive as that
given by HIP can be managed. However, when
families must pay the entire premium for HIP and
Blue Cross, as is true under our individual enroll-
ment policies in both urban and rural experiments,
it appears from our experience that relatively few of
them will purchase coverage of that extent. After
six years of effort in a farm area where average
family incomes are less than $3,000 a year, only 820
persons in a population of about 50.000 are insured.
When HIP offered coverage to persons and families
not in groups and they had to pay the full cost of
HIP and Blue Cross (the full cost amounting to more
than $300 a year at new group rates for a family
with one or more children) fewer than 10,000 per-
sons in New York City became insured. The insur-
ance offered was considered attractive, taking in
persons with diabetes, epilepsy, asthma, heart dis-
ease and most other chronic conditions as well as
persons requiring surgical treatment, but apparently
was too costly for most family budgets.

Several features in a group practice prepayment
plan of the HIP type make the provision of a broad
scope of coverage easier and less costly than most
indemnity plans:

1. A partnership of 20 to 60 physicians working
together in a medical group center with an x-ray
department, laboratory, physical therapy depart-
ment and central record room has the potential
for a more efficient and economical service than the
same number of physicians with similar equipment
in solo practice. For example, the Permanente
Medical Group in Southern California has one cen-
tralized laboratory for all diagnostic tests — except
urine, blood cell counts and hemoglobin determina-
tion— for over 300,000 members. One has to see
the actual cost data for each type of test and see
the experience of such fully automated laboratories
to appreciate how efficient and economical this can
be, in addition to improving the quality of work.

2. When there are no fees to discuss or collect
and no insurance forms to fill out for indemnities,
physicians have more time for service to their
patients.

3. With a team of physicians in a medical center,
they can take over for one another during illnesses,
vacations, hours off or emergency periods, so that
the medical needs of patients can be served more
readily at all times, including emergency services at
night or on weekends.

4. Payments for medical care on a capitation
basis rather than fee for service avoids financial
incentives for unnecessary medical or surgical serv-
ices. Studies of the hospital admission rates have
shown they are 20 per cent lower for members of
prepaid group practice plans than for identical
populations under fee-for-service plans in New York.
Imagine the increased scope of medical care cover-
age which could be purchased in the United States
if the cost of hospital insurance could be decreased
20 per cent!

Other professional services

In a medical care plan such as HIP we find it
important to provide services of other professional
workers besides physicians. I have already men-
tioned unlimited visiting nurse services. Most of this
service is for chronically ill persons at home.

We have on our central staff five highly skilled
“Community Resources Consultants” who serve all
our medical groups. These consultants are, of
course, social workers with many years of experi-
ence in New York City and are thoroughly familiar
with all of the more than 2,000 voluntary or public
agencies in fields related to health. They know what
services these agencies provide, the eligibility re-
quirements, if any, and how referrals should be
made for prompt and effective action. The problem
for the consultant to deal with may concern such
things as convalescent home care, extensive re-
habilitation, terminal care for cancer patients at
home, admission to a mental institution, care for
a mentally retarded child, the need for a brace or
hearing aid, etc. Few if any physicians have the
knowledge or time to make arrangements for such
service. We have found consultation of this type a
very valuable part of our program.

We have two full-time nutritionist-dietitians who
work with all our medical groups, helping the
physicians prepare dietary instruction sheets, dis-
cussing dietary problems with separate groups of
diabetic, obese or hypertensive patients, and serving
in individual consultation for the more difficult diet
problems, referred by physicians. This is all for the
ambulatory office patients and is not related to in-
hospital dietary problems. This service has been
found to be not only a time saver for the physicians,
but, even more important, a specialist in the field
is more aware of the racial, religious and economic
problems related to diet instructions and is often
more up to the minute in new knowledge in the
field of nutrition than the average physician.

Although every physician is a health educator,
we have found that a staff of five specialists in the
field (the Director has a Ph.D. in health education)
has been welcomed by both physicians and patients.

VOL. 97, NO. 2 • AUGUST 1962

Each medical group has regular meetings of sub-
scribers at which a wide range of topics in the
field of health is discussed, the meeting usually
being held in public school auditoriums. Subjects
such as the Adolescent Girl. Mental Health. Health
Problems of Older People, Allergies, Vitamin
Quackery, the Doctor and his Equipment. Cancer,
etc., are covered. Subscriber committees may help
select the topics. The doctors in the medical groups
who are best informed on the subjects are the dis-
cussion leaders. More intensive health education
discussions with small groups of patients with the
same illness, such as diabetes, hypertension and
obesity, have also been developed.

In addition, regular health bulletins go to all
insured families from each medical group. The
bulletins carry important health information on a
wide range of health and administrative topics and
up-to-the-minute important information. For ex-
ample, when the Salk vaccine came out. every family
was urged to get every member immunized promptly
and most of the 31 medical groups set aside special
hours on evenings and weekends to accommodate
them. For a year afterwards, reminders to get Salk
vaccinations were published, urging completion of
the recommended schedule of injections. Home
calls, a medical problem all over the country and
particularly serious in the East, has been the sub-
ject of a whole series of health education articles
in an effort to achieve better understanding on this
matter between patients and physicians.

One cannot discuss scope of service without
giving serious consideration to the quality of service.
A broad scope of inferior quality might cost the
same as a narrower scope of high quality. Since
HIP is responsible for providing medical care for
(not cash benefits to) its 637.000 enrollees, it must
be directly concerned with the quality. A medical
board, a majority of whose members are leaders
from medical schools and teaching hospitals, has
for 14 years established professional standards and
approved the qualifications of training and experi-
ence for each of the 1.000 participating physicians.
One of the earliest standards was that maternity
care would be provided only by board-qualified
specialists in obstetrics and gynecology, and that
pediatric care of young children would be provided
only by board-qualified pediatricians. All special-
ists are required to be either board certified or.
for the younger assistants in a department, to have
completed residency requirements of their board.

The most important member of a medical team,
we call the family physician. Our current require-
ments for family physicians are two years’ approved
residency in medicine after internship. Each adult
in HIP picks his own family physician in the medical
group to whom he goes for health examinations as

well as for any illness. The family physician is
responsible for the medical work-up, diagnosis and
treatment of his patients. If the skills of any of
the group specialists are needed for consultation or
surgical operation, appropriate referrals are made.

Scope of service is not static

One of the most fascinating features of medical
care administration is the changing pattern of
medical practice resulting from new knowledge in
the scientific field. For example, since HIP covered
all types of surgical treatment, when operations on
the heart became successful in the late 1940’s, in-
sured persons were sent to Johns Hopkins and we
paid for the services of Dr. Taussig and Dr. Blalock.
Now this service is provided for us by several teams
of skilled cardiac surgeons in New York City. This
is one of dozens of examples of a completely un-
predictable increase in the cost of a comprehensive
medical care program.

When the Salk vaccine became available, its
utilization by HIP members substantially increased
total office utilization rates over a period of two
years. I presume this utilization will be more than
compensated for by the long-range reduction in
the number of patients with paralytic poliomyelitis.

We are currently helping in the testing of the new
measles vaccine. When it is approved and generally
available, within a year or two, we will endeavor
promptly to vaccinate all children covered by HIP.

Working with the New York Association for the
Blind, we are endeavoring to assure early detection
of glaucoma by routine tonometric examination,
done at least once a year by specially trained
nurses and technicians, of all persons over 40 years
of age. No one questions the importance of this
service but it is not routine in health examinations
by either family physicians or ophthalmologists;
and as it is introduced into a medical care program,
it takes time and adds to the total cost of medical
care.

A more dramatic development is the use, by a
team of skilled specialists, of an artificial kidney for
certain serious illnesses. It is not needed very often,
but when it is needed, it is a life-saving measure.
The cost is very high.

The many new scientific developments in medi-
cine each year must be encompassed in a medical
care plan such as hip. Coverage of new advances
often increases the total cost of providing service.

Prepaid group practice offers the possibility of
the most comprehensive scope of health insurance
through its more efficient and economic organiza-
tion and its control of quality.

Health Insurance Plan of Greater New York, 625 Madison Ave.,
New York 22.

CALIFORNIA MEDICINE

Fatigue Fractures in Track Athletes

MARTIN E. BLAZINA, M.D., ROBERT S. WATANABE, M.D., and
ELYIN C. DRAKE, L.P.T., Los Angeles

Unlike THE USUAL MUSCLE pulls and ligamentous
sprains that one encounters in the physical care of
track athletes, which are invariably related to a
specific traumatic episode, fatigue fracture is usually
not associated with a definite injury. With aware-
ness of certain peculiarities in the clinical pattern,
however, one can come to a tentative and ultimately
a definite diagnosis in these sometimes perplexing
cases.

Clinical Aspects

Typically the athlete, most often a middle-distance
runner, complains initially of insidious onset of an
aching or soreness of a leg or foot not unlike that
of leg or foot strain, or “shin splints.” Most com-
monly, the pain is localized to the lateral region
over the distal fibula. In some instances it may be
in the lateral portion over the proximal fibula, and
occasionally over the medial aspect of the shin.
If the foot is involved, the tenderness is over the
affected metatarsal bone. The discomfort is made
worse by running and will lessen or abate with rest
or ordinary walking. The usual measures of whirl-

From the Department of Surgery/Orthopedics, University of Cali-
fornia Medical Center, and the Department of Intercollegiate Athletics,
University of California at Los Angeles, Los Angeles 24.

Submitted February 2, 1962.

• Pain in a foot or in the lower leg, not related
to specific injury, in a track athlete who does a
great deal of running, is the first symptom of
fatigue fracture. X-ray films taken at the time
pain begins may show no abnormality. Films
taken a month or more later may show formation
of callus, and perhaps a fracture line, at the
point of pain.

Usually no treatment beyond cessation of run-
ning for two months or more is needed.

Since the incidence is highest in middle-dis-
tance runners who train intensively — quarter-
milers in particular — and may be related to the
hardness of the running track, limiting running
to alternate days and doing part of it on grass
may help in prevention.

pool or manual massage, taping or local injections
of cortisone give temporary relief but on resump-
tion of vigorous running the symptoms recur.

Upon physical examination tenderness will be
noted over the bone at the involved site. Although
the tenderness may appear to extend along the peri-
osteum or tendinous structures for some distance
either proximally or distally, there is always a point
of maximum intensity at the point of fracture.

Usually the pain spontaneously subsides after
three or four months if the athlete does no running,

Figure 1. — (Case 1). Left, x-ray film at time of onset of pain in distal fibula, showed no abnormality. Right, x-ray
two months later showed obvious healed fracture at site of previous pain.

VOL. 97, NO. 2 • AUGUST 1962

and training then can be resumed. Occasionally, the
symptoms are more prolonged and an entire season
may pass without a return to competition.

Roentgenologic Studies

At the onset of symptoms, roentgenologic exam-
ination, including spot films, may show no evidence
of fracture (Figures 1, 2. 4). After three to four
weeks, a localized area of periosteal irritation may
be noted, and sometimes a faint radiolucent line tra-

Figure 2. — (Case 2). X-ray film, taken after two months
of pain localized in upper lateral aspect of the leg, inter-
preted as showing healing fatigue fracture of upper fihula.

versing the width of the involved bone may be
visualized (Figure 3). After eight to twelve weeks,
near the time of abatement of symptoms, x-ray films
will show formation of callus, occasionally about an
obvious fracture line (Figures 1, 2, 3, 4). In most
instances, this observation will establish a diagnosis
that has been elusive up to this time.

Treatment

Since ordinary activity usually is not particularly
painful, immobilizing the site of fracture is not
often necessary, although if symptoms are severe a
walking plaster cast may be necessary.

Discussion

Prevention of fatigue fracture depends upon al-
tering the training program. Such lesions, which
occur most frequently in athletes who run the mid-
dle-distance events, appear to be related to the
intensiveness of the training program and perhaps
to the hardness of the running track. Most coaches
therefore instruct their runners not to work out
vigorously every day and to do part of their training
on grass or soft courses. That the nature of the
running specialty is related to fatigue fracture is
indicated by the relatively high incidence of such
lesions among quarter-milers, who must keep a
strong pace from the very beginning of the race and
sprint at the finish. In their training program, these
runners must do sprints for speed and run distances
for endurance. This combination of requirements
might lead to the development of fatigue fracture.

Figure 3. — (Case 3). Left, x-ray film taken soon after beginning of pain over middle of shin, showing no abnor-
mality. Center, film three weeks later showing periosteal reaction along medial aspect of mid-tihia. Right, after an-
other three months an x-ray film showed a healing fatigue fracture of the tibia.

CALIFORNIA MEDICINE

Figure 4. — (Case 4). Left, film at time pain in foot fie
showed healing fatigue fracture of the shaft of the third m

REPORTS OF CASES

Case 1. A 19-year-old quarter-miler complained
of pain of recent onset localized to the distal fibula.
No abnormality was noted on x-ray examination
(Figure 1). The patient quit running for some two
months, then resumed training. X-ray films taken
after he had returned to active running showed an
obvious healed fatigue fracture of the distal fibula.

Case 2. An 18-year-old quarter-miler had pain of
two months’ duration localized to the upper lateral
aspect of the leg. X-ray films were interpreted as
showing a healing fatigue fracture of the upper
fibula ( Figure 2 ) .

Case 3. A 17-year-old half-miler had pain that

gan, showing no abnormality. Right, a month later a film
etatarsal hone.

had begun only a short time before over the middle
of the shin. No abnormality was observed in x-ray
films. Films taken three weeks later showed peri-
osteal reaction along the medial aspect of the mid-
tibia. and after another three months had passed a
healing fatigue fracture of the tibia was shown
(Figure 3 ) .

Case 4. A 19-year-old quarter-miler noted pain
in his left foot, especially over the third metatarsal
bone. X-ray films showed no abnormality. Films
taken a month later revealed a healing fatigue
fracture of the shaft of the third metatarsal bone.
(See Figure 4.)

Department of Surgery, U.C.L.A. Medical Center, Los Angeles 24
( Blazina) .

Bronchial Division in the Treatment of
Pulmonary Tuberculosis

JOHN D. STEELE, M.D., San Fernando

The use of bronchial occlusion as treatment for
tuberculous cavities was advocated at least 25 years
ago, principally by Adams1 and by Coryllos.5 In
most of the early clinical cases, occlusion was
brought about by cauterization.

In 1952, in the German literature Nissen and
Lezius0 reported 16 cases of advanced cavitary tu-
berculosis treated by bronchial ligation and division.
Impressed with the results, Bogush,2 in Russia,
operated on 50 patients and reported the results in
1957. Cavity closure was obtained in 43 cases.

Independently Chamberlain of New York started
using bronchial ligation in 1948 and reported on a
series of 25 cases in 1960. Chamberlain and Mc-
Neill’s4 communication, the most comprehensive
to date on the subject, reviews considerable histori-
cal and experimental background.

In the present study, bronchial division was used
in seven male patients for whom no other surgical
procedure was feasible. The results in three of these
patients were good. In another the sputum became
negative for tubercle bacilli but at last report there
was a small residual empyema pocket as a compli-
cation of the operation. It was expected to heal. Two
patients died. Another had a spread of disease, fol-
lowed by recanalization of the bronchus, and the
sputum remained positive.

In recent personal communications, Chamberlain*
said that his current results with this operation are
running about 50 per cent good. He still does not
understand why one patient does exceedingly well
and in the next all sorts of complications develop.

Brief case reports of the seven patients operated
upon by the author follow. A wide variety of com-
plications were encountered.

Case 1. A 62-year-old man had a right thora-
coplasty for a right apical cavity in 1957 (Figure 1,
upper left). The cavity was not closed by the opera-
tion (Figure 1, upper right and 1, lower left) and
the sputum remained positive. The organisms in
this patient had become resistant to the major anti-
tuberculosis drugs. Since his respiratory reserve

From the Veterans Administration Hospital, San Fernando, and
the Department of Surgery, University of California, Los Angeles 24.

Read at a meeting of the California Thoracic Society, San Diego,
February 9, 1962.

Submitted March 15, 1962.

• Bronchial division was carried out in seven
patients with tuberculosis for whom no other
procedure was feasible. Results were good in
three cases. Complications developed in another
case but the ultimate result was expected to be
good. Two patients died. One had spread of dis-
ease and recanalization of the bronchus.

was low and it was feared that resection might entail
pneumonectomy, bronchial occlusion was decided
upon. The right upper lobe bronchus was divided in
August, 1960. The postoperative course was ex-
tremely smooth and cultures of sputum and of
gastric contents for tubercle bacilli promptly be-
came negative. The cavity disappeared (Figure 1,
lower right ) and the patient was discharged.

Case 2. A man of 47 with tuberculosis far ad-
vanced when it was discovered in 1959 had a cavity
remaining at the right apex after 10 months of
chemotherapy. The sputum remained positive on
culture and the organisms had lost their suscepti-
bility to the major antituberculosis drugs. On Aug-
ust 30, 1960, the right upper lobe bronchus was
divided after the lung had been mobilized extra-
periosteally as suggested by Chamberlain. The
extraperiosteal space contained air for two months
but finally filled with fluid. A few weeks later it
contained air again, and it was then realized that a
bronchopleural fistula had developed. Drainage of
emphysema and a thoracoplasty were carried out.
The sputum became negative for tubercle bacilli
but a small residual empyemic pocket (which was
healing rapidly at the time of this report) remained.

Case 3. The patient was a man 42 years of age
who had advanced silicotuberculosis with bilateral
cavitation that had been treated for many years
with various antituberculosis drugs. The left side
was operated upon first. After extraperiosteal mo-
bilization of the lung, the apical-posterior segmental
bronchus was divided. Because of dense scarring
and matted silicotic nodes at the hilum, the anterior
segmental bronchus could not be reached. The
anatomical configuration of the left hilum, of course,
makes dissection of the upper lobe bronchus more
difficult and hazardous than dissection on the right.
The cavity decreased in size only temporarily after

CALIFORNIA MEDICINE

Figure 1. — (Case 1). Picture at upper left, right apical tuberculous cavity for which thoracoplasty was performed
in 1957. In the picture at upper right, cavity still present beneath right thoracoplasty. At lower left, the cavity is
seen better on a planigram. In roentgenogram at lower right, the cavity is no longer seen after bronchial division. The
aerated area beneath the thoracoplasty is emphysematous lung tissue.

the operation. When it again reached its original
size, cavernostomy and thoracoplasty were done,
reducing the cavity to a narrow sinus. Even though
the patient’s respiratory reserve was extremely low.
division of the right upper lobe bronchus was at-
tempted. During dissection of the hilum which was
matted with silicotic nodes, the patient died of un-
controllable hemorrhage from the pulmonary artery.

This case illustrates difficulties that may be en-
countered in attempting division of the left upper
lobe bronchus as well as special hazards associated
with silicosis.

Case 4. The patient, a 35-year-old man, had far
advanced, bilateral pulmonary tuberculosis. Al-
though the sputum rather promptly became negative
for tubercle bacilli, a large cavity remained at the
right apex and there was residual disease throughout
the remainder of the lung. Instead of an extraperios-

teal procedure, the right upper lobe bronchus was
divided and a three-rib thoracoplasty was carried
out. Convalescence was uneventful.

Case 5. The patient, a 34-year-old Oriental man.
with mental disease, had far advanced bilateral
tuberculosis (Figure 2) which apparently responded
fairly well to chemotherapy, leaving what appeared
to he a shrunken, destroyed right upper lobe ( Figure
2, upper right and lower left ) . Thoracotomy was
performed with the intention of carrying out right
upper lobectomy. However, much more extensive
disease was found than was suspected from the
roentgenogram. Large dense, caseous lesions in-
volved both the middle lobe and superior segment
and extended across the fissures. Instead of carry-
ing out pneumonectomy, or leaving the inferior
division of the lower lobe, which would have re-
quired an extensive space filling procedure, division

VOL. 97. NO. 2 • AUGUST 1962

Figure 2. — (Case 5). Picture at upper left is pretreatinent roentgenogram showing far advanced bilateral pulmo-
nary tuberculosis. At upper left is a roentgenogram taken after eight months of antituberculosis chemotherapy. The
planigram at lower left, taken preoperatively, shows shrunken right upper lobe with cavitation. The picture at lower
right is a postoperative roentgenogram taken three months after division of the right upper bronchus and three-rib
thoracoplasty.

Figure 3. — (Case 6). Left, roentgenogram after 11 mo
apical cavity. Center , roentgenogram taken two days after
thoracoplasty, showing ca\ity definitely smaller. A contrast
Right, bronchogram taken two months postoperatively, sho

iths of antituberculosis chemotherapy, showing large right
division of the right upper lobe bronchus and three-rib
medium had been instilled into the cavity at operation,
ling cavity much larger and recanalization of the bronchus.

CALIFORNIA MEDICINE

of the right upper lobe bronchus and a three-rib
thoracoplasty was decided upon. The postoperative
course was smooth and prompt shrinkage of the
upper lobe occurred. At last report the sputum was
negative on culture.

Case 6. The patient was an Apache Indian, 30
years of age. After 1 1 months of treatment with
antituberculosis drugs, he had a huge right apical
cavity (Figure 3) even though the sputum had
become negative. His respiratory reserve was low
and he was slightly dyspneic. The right upper lobe
bronchus was divided and a small amount of con-
trast medium (Dionosil®) was instilled through the
distal bronchial stump in order that the cavity could
be observed roentgenographically. At the same time
a three-rib thoracoplasty was done. A film taken on
the second postoperative day showed the cavity to
be smaller (Figure 3, center). However, the cavity
then became progressively larger and a bronchial
fistula was demonstrated both by needle aspiration
of the cavity and by bronchographic examination
(Figure 3. right). The patient died suddenly two
and a half months postoperatively from right heart
failure with pulmonary edema. At autopsy, the
bronchus was found to be recanalized despite the
fact that at operation the cut ends had been sepa-
rated by at least 3 cm.

Case 7. The patient, a 59-year-old man, had had
tuberculosis for many years with known cavitation
and postive sputum for at least ten years in spite of
the administration of many different antituberculosis

drugs. The maximum breathing capacity was 43
liters per minute and the 3-second vital capacity was
55 per cent (normal 94 per cent). The right upper
lobe bronchus was divided and a 3-rib thoracoplasty
was done. The patient did well for three weeks but
then had a massive spread of disease, the lesions in-
volving the middle lobe and the anterior segment of
the upper lobe. This cleared later, at least at the
base, but cavities reappeared, indicating recanaliza-
tion of the bronchus. Incidentally, Bogush2 reported
five cases of recanalization although he did not spe-
cify as to whether he divided or merely ligated the
bronchi in those cases.

Veterans Administration Hospital, San Fernando.

REFERENCES

1. Adams, W. E., and Vorwald, A. J.: The treatment of
pulmonary tuberculosis by bronchial occlusion, J. Thor.
Surg., 3:633, 1934.

2. Bogush, L. K. : Pereviaska bronkhov kak noviji

lechenia kavernosnogo tuberkulesa (bronchial ligation as a
new method for treatment of tuberculosis with cavitation),
Sovetskaia Meditsina, 21(6) :45-50, 1957.

3. Chamberlain, J. M.: Personal communications, Sept.
14, 1961, and January 16, 1962.

4. Chamberlain, J. M., and McNeil, T. M.: Ligation and
division of the bronchus in the surgical treatment of cavi-
tary tuberculosis, J. Thor, and Cardiovas. Surg., 40:475,
1960.

5. Coiyllos, P. N. : The Surgery of Pulmonary Tubercu-
losis, New York, 1937.

6. Nissen, R., and Lezius, A.: Der Verschluss des Drana-
gebronchus als selbstostandiges oder erganzedes Behand-
lungsverfahren bei der kavernosen Lungentuberkulose,
Deutsche med. Wchnschr., 13:385, 1952.

VOL. 97

AUGUST 1962

Double Aortic Arch

CLIFFORD F. STOREY, M.D., San Diego

Six pairs of branchial arches are present in early
embryonic life and the aortic arch normally arises
from the fourth left branchial arch. The distal por-
tion of the right fourth arch normally becomes
obliterated and the proximal segment becomes the
first part of the subclavian artery. If the left rather
than the right arch undergoes resolution, a right
aortic arch results. When both arches persist a com-
plete vascular ring surrounds the esophagus and
trachea, one arch (usually the larger) passing be-
hind those structures to join the smaller anterior
arch in that hemithorax in which the proximal
thoracic aorta descends.

The presence or absence of symptoms due to a
double aortic arch depends upon the size of the ring.
If it is large there will be no significant com-
pression of the trachea or esophagus and the
patient will be free of complaints. If there is a
tight constriction of these structures, a classic com-
bination of symptoms results. These consist of
(1) stridor, which is both inspiratory and expira-
tory in type, (2) dysphagia, (3) attacks of cya-
nosis, particularly with feeding, (4) suprasternal,
supraclavicular, substernal and subcostal retraction
on inspiration, (5) a harsh, barking cough, and
(6) a strong predilection to pulmonary compli-
cations.

The seriousness of this malformation and the
necessity for proper surgical treatment in sympto-
matic infants is indicated by the report of Griswold
and Young.1 They described 19 patients with double
aortic arch. In 14 of them the defect was not recog-
nized during life and all of them died. The diagnosis
was established in five cases and the patients were
operated upon. In three of them, one component
of the double aortic arch was divided and all three
lived and did well. In two cases the constricting
vascular ring was not divided and neither of the
patients survived.

The symptoms resulting from this anomaly are
often mild at birth and in the early days or weeks
of life, but with growth and development and in-
creasing arterial pressure they may become more
alarming if not intolerable. However, numerous
children born with this lesion have survived a
number of years before they died of pulmonary
complications attributable to it, or upon correct
diagnosis have been relieved by proper surgical
treatment.

Submitted March 9, 1962.

• The recognition of a double aortic arch which
causes significant constriction of the esophagus
and trachea is relatively easy if the cardiac symp-
toms caused by this anomaly are borne in mind.
Once suspected, the diagnosis may be confirmed
readily by radiographic examination of the
esophagus with a barium swallow. The treatment
consists of division of the ductus arteriosus (or
ligamentum) and of the smaller component,
usually the anterior, of the double aortic arch.

The symptomatology associated with a double
aortic arch is so characteristic that the diagnosis
may be strongly suspected on the basis of clinical
history alone. Verification may be obtained by
fluoroscopic examination and films of the esopha-
gus after a swallow of contrast medium. The lateral
projection will demonstrate sharply localized an-
terior displacement of the esophagus at the level of
the aortic arch. In the postero-anterior view com-
pression of the esophagus from both the right and
left sides will be noted. This condition can also be
diagnosed by tracheography, bronchoscopy, esopha-
goscopy and angiocardiography or aortography, but
these more complicated studies usually are unnec-
essary. It is important for the radiologist to deter-
mine, if possible, the hemithorax in which the
proximal descending thoracic aorta is situated, for
the ligamentum arteriosum usually lies in this chest
and the surgical approach should be made through
the corresponding side.

The surgical objective is to divide the constricting
vascular ring. This seems relatively simple and
straightforward, and indeed that may be the case.
However, there are a great many possible com-
binations of this anomaly and the situation encoun-
tered at operation is apt to be confusing initially.
It is imperative that the ring be divided at the most
advantageous site in order to relieve completely the
pressure on the trachea and esophagus yet not
interfere with blood flow through any major vessel.
Good exposure and careful dissection permit the
surgeon to visualize and understand clearly the
exact anatomical arrangement of the involved ves-
sels. Thereafter surgical correction poses no par-
ticular difficulty. Usually it is most advantageous
to divide the smaller anterior arch between the left
common carotid and the left subclavian arteries.
The ligamentum arteriosum (or ductus arteriosus)
must also be divided.

CALIFORNIA MEDICINE

Figure 1 (Case 1). — Left, Right lateral chest roentgenogram with a swallow of iodized oil. Note anterior dis-
placement of posterior esophageal wall at the level of the aortic arch. The esophageal displacement assumes a slightly
oblique configuration from above downward from right to left. Right , Postero-anterior chest roentgenogram with
iodized oil swallow'. The compression of the esophagus from both the right and left sides at the level of the aortic
arch is demonstrated well. The obliquity of the compression is again shown.

VA3LULAR CAMPREASIANT AF RSOFHAGLLS AMD TRA.CMELA.

Dcubla. A^rKc Amli -walk Lar^>2- Posierjar" Limb and 5malliz.r An J-eJ'iAr Limb

FrojifV lew _ Paik.rmrV.ie.w _P*-2: Fra n FV j &w_ pxmd 4 h/c_

Figure 2. — Diagrammatic representation of the anomaly encountered in Cases I and II while C. illustrates the
essential points in the surgical treatment of these patients. (In an experience with four cases, it has not seemed neces-
sary to tack the proximal segment of the divided anterior arch to the inner surface of the overlying sternum, as Gross2
has recommended, in order to relieve adequately the pressure on the trachea.)

VOL. 97, NO. 2 • AUGUST 1962

REPORTS OF CASES

Case 1. The patient, a girl baby, was delivered
spontaneously at term. Inspiratory and expiratory
stridor with suprasternal, supraclavicular and sub-
costal retraction on inspiration was noted immediate-
ly after birth. The respiratory difficulty was aggra-
vated by feeding, and cyanosis occurred frequently
when the baby was given the bottle. A loud wheeze
was audible, most pronounced in the midsternal
region, but it could be heard clearly over both sides
of the chest. The stridor, retraction, and cyanosis
with feeding were relatively mild during the first
few days of life but they became rapidly and
progressively more severe. When the patient was
six weeks old, roentgenograms after a swallow of
iodized oil demonstrated the typical deformity
caused by a constricting vascular ring (Figure 1).
Left thoracotomy was performed the following day
and the classic configuration was found. There was
a large right aortic arch which coursed to the left
posterior to the esophagus to join a somewhat
smaller anterior arch which passed in front of those
structures. The junction of the two arches to form
the descending thoracic aorta occurred just distal
to the origin of the left subclavian artery. The
latter vessel as well as the left common carotid
artery arose from the smaller anterior arch, while
the innominate artery was the first branch of the
larger posterior arch. A large and rather long duc-
tus extended from the anterior arch just distal to
the origin of the left subclavian artery and just
proximal to the union of the two arches to the left
main pulmonary artery below. The ductus was
divided between vascular clamps and was found to
contain a thrombus. The anterior component of the
double aortic arch was then divided between the
left common carotid and the left subclavian arteries
(Figure 2). This effectively relieved the compres-
sion of the esophagus and trachea. Postoperatively
the patient prospered. Growth and development
from then on were normal and she has been com-
pletely free of dysphagia and respiratory symptoms.

Case 2. A boy baby weighing 2 pounds 8 ounces
at birth was delivered in the seventh month of
gestation by cesarean section. The mother had
placenta previa with life-threatening hemorrhage.
Although the baby obviously was premature, no
gross abnormalities were apparent on physical ex-
amination shortly after birth. Flowever, inspiratory
and expiratory stridor with suprasternal, supracla-
vicular and subcostal retraction on inspiration were
noted. These symptoms were aggravated by feeding
and the baby suffered attacks of cyanosis which
occurred only when he was fed. The infant’s diffi-
culties were relatively mild in the neonatal period
but his symptoms increased steadily in severity.

Figure 3 (Case 2). — Right lateral chest roentgenogram
with swallow of Hypaque® showing typical anterior dis-
placement of the posterior esophageal wall at the level of
the arch. During the radiographic examination, this pre-
mature and seriously ill infant became cyanotic as soon
as he was given the swallow' of contrast medium and cir-
cumstances did not permit taking a postero-anterior film.

With superb nursing and pediatric care the baby
reached an age of 82 days. At this time he had a
loud inspiratory and expiratory wheeze that was
heard best over the mid-sternal area but was clearly
audible throughout both lung fields. Fie frequently
became deeply cyanotic when fed and total apnea
often developed on such occasions, requiring vigor-
ous resuscitative measures for survival. Radiogra-
phic examination of the esophagus after a swallow
of 90 per cent Hypaque® confirmed the presence of
a double aortic arch (Figure 3). He was operated
upon when 84 days of age and the anomaly in this
case was almost identical to that found in Case 1.
The ductus arteriosus was patent. The surgical
procedure carried out was precisely the same as that
described in Case 1. This completely relieved the
constriction of the trachea and esophagus. Post-
operatively the baby did well. He was able to swal-
low without difficulty, he no longer became cyanotic,
and the other symptoms formerly associated with
constriction of the vascular ring disappeared.

Alvarado Medical Center, 6330 Alvarado Road, San Diego 20.

REFERENCES

1. Griswold, H. E., Jr., and Young, M. D.: Double aortic
arch. Pediatrics, 4:751, 1949.

2. Gross, R. E.: Surgical relief for tracheal obstruction
from vascular ring, N.E.J.M., 233:586, 1945.

CALIFORNIA MEDICINE

Compression Neuropathy of the Ulnar Nerve

A Common Condition Occurring at Bed Rest

M. N. ESTRIDGE, M.D., and ROGER A. SMITH, M.D., San Bernardino

The syndrome of ulnar nerve palsy occurring at
bed rest has long been recognized. Sir William
Gowers3 noted in 1886 that many patients sleeping
with the elbow flexed complained of tingling and
loss of sensation in the region supplied by the ulnar
nerve. He observed also that if this condition was
superimposed on profound ill health, intense local-
ized neuritis could result. Gowers cited a case of
ulnar nerve palsy occurring in a woman recovering
from a long prostrating labor. Since that time bed-
rest ulnar palsy has been mentioned in many of the
standard text hooks of medicine, but given little
further regard. When we directed our attention to
this condition it became apparent that it was a
common syndrome occurring in many patients lying
in hospitals. In the majority of cases the palsy was
mild and improved without any particular treat-
ment. The following cases, which were among the
more severe, illustrate this syndrome.

REPORT OF CASES

Case 1. A man 57 years of age fractured his
pelvis in a fall on November 23, 1953. Several
days later numbness of the ulnar side of both hands
was noted. Weakness followed in a few days, and
later atrophy of the interosseous muscles. Electrical
stimulation was given for two months without bene-
fit. On examination two and one-half years later
there was moderate atrophy of the hypothenar
eminence and interosseous muscles of both hands,
with severe weakness of adduction and abduction
of the fingers, weakness of the deep flexors of the
ring fingers and little fingers and sensory loss in
the area of distribution of the ulnar nerve on the
dorsum and palm of both hands. The ulnar grooves
were shallow. The nerve was slightly tender and
questionably enlarged, but did not subluxate. An
electromyogram was reported as showing bilateral
abnormalities consistent with neuropathic changes
affecting the ulnar nerve at the elbow. No changes
were found above the elbows or in the lower ex-
tremities.

From the Neurosurgical Service, St. Bernardine’s Hospital, San
Bernardino.

Submitted December 13, 1961.

• Compression neuropathy of the ulnar nerve
at bed rest appears to he quite common. The
symptoms are dysesthesia, weakness and later
atrophy in the area of distribution of the nerve.
Special attention is required for prevention or
for early discovery of the condition in time for
treatment to bring about prompt recovery.
Physical therapy with electrical stimulation may
be useful in the more severe cases. When the
condition is progressive or recalcitrant, anterior
transplantation of the nerve may he necessary.

Examination on March 11, 1960, showed slight
progression of the weakness.

Comment: At first it was thought that the patient
might have had injuries of the ulnar nerves at the
time of the pelvic fracture, hut he denied any
symptoms referable to the ulnar nerve until several
days after the accident. The ulnar nerve palsy
apparently progressed during the five weeks of bed
rest, and worsened after ambulation.

Case 2. A 28- year-old painter fell 15 feet from
a scaffold, landing on the right side of his chest
and head, and was unconscious for three days. The
first, second and third ribs on the right side were
fractured. Also present were subcutaneous emphy-
sema, pneumothorax and a linear fracture of the
right parietotemporal region of the skull. X-ray
films of the cervical spine showed no abnormality.
Ten days after the injury, numbness of the little
and ring fingers developed but the patient did not
call his physician’s attention to the condition. A
month after leaving the hospital the patient noticed
wasting of the small muscles of the hand.

Seven months later examination revealed atrophy
and weakness of the small muscles of the hand sup-
plied by the left ulnar nerve, and sensory loss out-
lining the distribution of the nerve. The ulnar
groove was adequate but the nerve was slightly
enlarged, and a tender nodule 1 cm. in diameter
was palpable on the nerve at the ulnar groove. An
electromyogram was reported to show extensive
denervation activity in the intrinsic hand muscles
supplied by the ulnar nerve, without changes in the
flexor carpi ulnaris or finger flexors. By 16 months
after the period of stay in hospital the atrophy and
weakness of the muscles of the hand had fully re-

VOL. 97, NO. 2 • AUGUST 1962

covered, but there was still a small area of dimin-
ished sensation on the radial side of the little finger.

Comment : The ulnar nerve lesion in this case
might have been attributed to the fall except that
the injuries then were to the right side of the body
with no evidence of injury to the region of the
ulnar nerve on the left. Also the patient denied any
ulnar nerve disturbance until several days after he
was admitted to hospital.

Case 3. A 41-year-old roofer fell six feet from
a ladder and received a compression fracture of the
first lumbar vertebra. There had been no apparent
injury to the elbow region. After nine days of bed
rest in hyperextension the patient noticed numbness
in the area of distribution of the ulnar nerve in
both hands. The condition improved on the left
side but progressed on the right, with increasing
atrophy of the small muscles of the hand and vague
cramping sensations in the elbow and forearm.

Eight months later there was atrophy of the small
muscles supplied by the ulnar nerve in the right
hand. No weakness of the flexor carpi ulnaris or
finger flexors was noted. Diminished sensation was
outlined in the ulnar nerve distribution. The ulnar
grooves were deep but the nerve was slightly
swollen and tender. There were no abnormal neuro-
logical findings in the left hand.

Electromyographic abnormality was found in the
flexor carpi ulnaris and in the small muscles of the
hand supplied by the ulnar nerve. Daily electrical
stimulation over a three-month period produced no
improvement. On the last examination, some 12
months after the onset of symptoms, it was noted
that there was a complete paralysis of the small
muscles of the right hand supplied by the ulnar
nerve and no change in the previously noted sen-
sory loss. Slight atrophy of the first dorsal interos-
seous of the left hand, without sensory loss, also
was noted. Anterior transplantation of the ulnar
nerve was recommended but was refused.

Case 4. A 44-year-old man was thrown from an
automobile in an accident and was unconscious for
four hours. He had fractures of the right seventh
and eighth ribs, the right scapula, right humerus,
left ankle and the transverse processes of the second,
third and fourth lumbar vertebrae. There was no
injury to the left elbow. He had fractured the left
elbow at age 10, with subsequent valgus deformity;
but never before had there been symptoms refer-
able to the ulnar nerve. One week after bed rest
in hyperextension the patient noted numbness in
the ulnar area of the left hand. Five months later
he had a gunstock deformity of the left elbow. The
ulnar groove was shallow and subluxation of the
ulnar nerve on flexion was noted. The nerve was

slightly swollen and tender. There was sensory
impairment in the area of the ulnar nerve distribu-
tion in the hand, with minimal atrophy. The small
muscles of the hand were weak. The patient could
not be reached for a later examination.

Comment: Consideration must be given to the
possibility of the ulnar palsy as a late sequel of the
fracture and deformity of the elbow in childhood.
However, the patient denied any symptoms referable
to the ulnar nerve before his stay in hospital, he
recognized the origin of his symptoms and was able
to avoid further progression of his condition.

Case 5. A 28-year-old man received severe in-
jury to the head, with subarachnoid hemorrhage,
bilateral abducens palsy and cerebellar contusion,
multiple rib fractures, rupture of the spleen and
renal contusion in an automobile accident. There
were no apparent injuries to the elbow. Upon neuro-
logical examination two weeks later, weakness of the
small muscles of the right hand and sensory loss in
the area of the ulnar nerve distribution were noted,
in addition to the injuries of the central nervous
system. The ulnar nerve in the right arm was
swollen and subluxation occurred on the flexion of
the elbow. The ulnar nerve in the left arm was also
tender but did not subluxate, and there was no
other neurological abnormality on this side. Prompt
restriction of pressure by use of soft pads under the
elbow stopped the progression of the ulnar palsy
and improvement began within a month. It was
no longer present six months later.

Comment: The time of the onset of ulnar palsy
was not known since the patient was confused and
did not spontaneously complain of difficulty. There
was no evidence of direct trauma to the elbow.
Prompt recognition of the condition and avoidance
of compression appeared to prevent progression.

Case 6. A 38-year-old man had fractures of the
pelvis, rupture of the urinary bladder and a week
of mental disorientation owing to an automobile
collision. There was no evidence of injury to the
elbows. He was immobilized in a body cast, and
approximately ten days after admission he com-
plained of numbness in the area of the ulnar nerve
distribution in both hands. He had supported him-
self on his elbows when turning in bed. Atrophy
of the small muscles of the hands on both sides was
noted three weeks later.

On examination seven months after the injury,
moderate weakness of the muscles supplied by the
ulnar nerve in the right hand was observed, with
a claw hand, atrophy of the interosseous muscles
and characteristic sensory loss. In the left hand
there was decided weakness of the muscles supplied
by the ulnar nerve, with atrophy and sensory loss.

CALIFORNIA MEDICINE

Electrical stimulation was advised, but the patient
did not return for reexamination.

Case 7. A 38-year-old woman received a fracture
of the right humerus and of the right ankle in an
automobile collision June 22, 1959. Both fractures
were treated by traction for three days, and then
casts were applied. There was no previous history
of paresthesia. Numbness of the ulnar side of the
left hand began June 29, 1959. Atrophy and weak-
ness of the hand were not definitely noted until
January 1960. On examination in March 1960,
diminished sensation in the area of distribution of
the ulnar nerve in the left hand, with weakness and
atrophy of all the muscles supplied by the ulnar
nerve, was noted. The ulnar nerve subluxated when
the elbow was flexed.

Anterior transplantation of the ulnar nerve was
carried out March 25, 1960, and the nerve was of
normal appearance except for subluxation on flexion
of the elbow. When the patient was examined No-
vember 1. 1960, there had been definite improve-
ment of strength. Paresthesia and atrophy were
diminished. On May 27, 1961, there was slight
atrophy but normal strength in the interosseous
muscles. No atrophy was discernible in the hypothe-
nar eminence. Froment’s sign* was present. So far
as could be determined there was no sensory loss.
Power in the finger flexors and flexor carpi ulnaris
was normal. The nerve was well anterior to the
epicondyle and was not tender.

Comment: The patient recalled that most of the
time she lay in bed her left hand rested on her
chest with the elbow resting flexed against the
mattress. This position brought about subluxation
of the nerve and allowed compression between the
bone and the mattress.

Case 8. A 31 -year-old man had repair of a
diaphragmatic hernia on February 13, 1959, and
his right arm was restrained to allow continuous
intravenous infusions. After three days he noticed
numbness of the right hand, which improved
slightly when the arm was released. After he began
walking he noted difficulty in using the hand, and
atrophy subsequently developed.

On examination six months later pronounced
weakness and atrophy of the hand muscles sup-
plied by the ulnar nerve were noted, as well as
weakness of the flexor carpi ulnaris and finger
flexors of the fourth and fifth fingers, with a flexion
deformity. Sensory loss could be outlined in the
area of distribution of the ulnar nerve in the hand.
The ulnar groove was shallow and the nerve was
slightly swollen but subluxation did not occur.

*When opposing the thumb to the first finger to grasp a paper,
the distal phalanx is sharply flexed to compensate for weakness of
the adductor pollicis muscle. Also called signe de journal.

The ulnar groove was examined surgically on
August 7, 1959, and the nerve was observed to be
slightly thickened in its lowest portion. Saline
solution injected into the sheath hesitated at the
mid-portion of the ulnar groove. The nerve was
transplanted anteriorly beneath the flexor muscles.

By May 17, 1960, the atrophy of the right hand
had improved, with normal power present in the
interosseous and adductor pollucis muscles. There
was distinct improvement in the forearm muscles
supplied by the ulnar nerve. Sensory impairment
was minimal.

Comment: The patient had observed no change
in his ulnar palsy in the six months after it began.
Although the findings at the time of operation were
minimal, definite improvement resulted from an-
terior transplantation of the nerve.

Case 9. A 27-year-old male who received a head
injury and fracture of the odontoid process in an
automobile accident in October, 1960, was treated
by traction upon Crutchfield tongs. Three weeks
after admission he noticed dysesthesia in the ulnar
nerve distribution of the right hand. Weakness and
slight atrophy followed. In March, 1961, there was
sensory loss in the distribution of the right ulnar
nerve with slight atrophy of the first dorsal interos-
seous muscle on both sides, but no other weakness.

Case 10. Four days after operation for repair of
a herniated intervertebral disk in the lumbar region
a 51-year-old man noticed numbness and slight
weakness of the small muscles of the right hand. A
protective sponge rubber pad was taped to the right
elbow and the patient avoided pressure on the ulnar
nerve but the weakness and sensory loss did not
improve. Anterior transplantation of the ulnar nerve
was carried out some three months later. Slight
swelling of the nerve was the only abnormality
noted. When seen seven months after the operation
the patient said numbness had abated in three
months. Examination showed only slight atrophy of
the first dorsal interosseous muscle with no weak-
ness of any of the small hand muscles.

Comment: Ulnar nerve palsy did not appear in
this case until several days after the spinal opera-
tion. Apparently it was caused by pressure against
the elbow when the patient turned himself in bed.
The ulnar palsy was on the same side as the bedside
table, a relationship previously mentioned by
Mumenthaler.6 This is the only case in which we
noted such a relationship. However, it was noted
that the palsy was more frequent on the uninjured
side of the body, suggesting that support of the
body on the elbow was a major factor.

VOL. 97, NO. 2 • AUGUST 1962

DISCUSSION

Many normal persons informed us that reading
in bed with the elbows resting against the mattress
would produce paresthesias in the hand after vari-
able periods. Lewis, Pickering and Rothschild5 in
1931, after a series of nerve compression experi-
ments, concluded that these temporary changes were
due to local ischemia of the nerve trunk. Denny-
Brown and Brenner2 showed that the cause of
persistent difficulty was the result of changes in the
nerve fibers and myelin sheath.

The cause of progression of the lesion following
removal of compression is not clear. We agree with
Conway1 that the ulnar nerve is ordinarily capable
of stretching sufficiently to compensate for motion
of the elbow hut are of the opinion that when in-
trinsic damage to the nerve impairs its elasticity
flexion and extension may produce repeated trauma
and progression of palsy.

The majority of the cases presented were in
patients who were confined to bed because of
trauma. However, the condition occurs also in pa-
tients who are confined to bed for other reasons.
It is probable that in many cases symptoms at-
tributed to toxic paralysis of a febrile illness are
in fact due to compressive neuropathy of bed rest.
It is apt to occur in patients confined in the
supine position, or those in whom mobility is im-
paired by paralysis, coma, or restraining devices.
The palsy was noted more often on the side op-
posite the injury. It is more common in patients
with a shallow ulnar groove or who have a history
of paresthesia in the hand following elbow com-
pression. We believe it is particularly likely to
occur when there is dislocation of the ulnar nerve.7
When the patient is supine with the elbow flexed
and the hand resting on the chest, the position of
the arm permits the ulnar nerve to dislocate onto
the medial aspect of the elbow, where it is com-
pressed. In some patients the nerve can be suffi-
ciently compressed between the bone of the ulnar
groove and the mattress to cause palsy.

The first symptoms — dysesthesia and weakness —
may appear a few hours to several days after bed
rest. Atrophy may develop later. Pain is unusual. In
some of the cases we observed, the forearm muscles
were not affected, probably due to anatomical varia-
tion of their nerve supply. When the condition is
recognized promptly and further nerve compression

avoided, spontaneous recovery is usual. Mumen-
thaler6 was unable to find a relationship between
the type of mattress and the development of the
paralysis. Despite padding of the elbow, progression
occurred in one of the patients we treated. A small
pillow under the posterior aspect of the arm and
forearm, suspending the elbow, offers the best
chance of relief of compression.

In the more severe cases physical therapy, espe-
cially electrical stimulation of the nerve, is admin-
istered. Anterior transplantation of the nerve may
be beneficial to patients who do not improve or in
whom the condition progresses.

In view of the frequency of the condition, special
attention should be given to prevention of ulnar
nerve compression in patients confined to bed for
a long time, especially if they must remain supine
or are immobilized. A history of paresthesias while
reading in bed, sitting in an arm chair, or driving
an automobile should be noted. The elbow should
be inspected for any abnormality of the carrying
angle, for shallowness of the ulnar groove, for
tendency of the ulnar nerve to dislocate when the
arm is flexed and for any unusual tenderness of
the nerve. When any of these conditions is found the
patient should be advised of the position of the
nerve, to avoid pressure against this region and to
report any dysesthesia promptly. Meals should be
served over the bed rather than on a bedside table
to avoid supporting weight on an elbow.

365 East Twenty-First Street, San Bernardino (Estridge).

REFERENCES

1. Conway, F. M.: Traumatic ulnar neuritis, Ann. Surg.,
96:425-433, Mar. 1933.

2. Denny-Brown, D., and Brenner, C.: Paralysis of nerve
induced by direct pressure and by tourniquet. Arch. Neurol.
Psychiat., 51:1-26, July 1944.

3. Gowers, Sir W. R.: Manual of Diseases of the Nervous
System, Philadelphia: P. Blakiston’s Son & Co., 1900.

4. Hunt, J. R.: Tardy or late paralysis of the ulnar nerve,
J.A.M.A., 66:11-15, Jan. 1916.

5. Lewis, T., Pickering, T. W., and Rothschild, P.: Sen-
sory pedal paralysis arising out of arrested blood flow to the
limb, including notes on a form of tingling, Heart, 16:1-32,
Oct. 1931.

6. Mumenthaler, J.: Ulnar nerve palsies in patients con-
fined to bed; its clinical significance in the light of 35 per-
sonally observed instances, Schweiz med Wschr, 88:591-595,
June 1958.

7. Wharton, H. R.: A report of 14 cases of dislocation
of the ulnar nerve at the elbow, Amer. J. Med. Sci., 109-110:
415-419, Oct. 1895.

CALIFORNIA MEDICINE

Surprises in Operations on the Inguinal
Area in Young Children

RICHARD M. MARKS, M.D., Encino

Perhaps the most common operative procedures in
infants and young children involve the inguinal area
for the repair of hernia, hydrocele and undescended
testicle.

Many of the unexpected findings in such opera-
tions are peculiar to children. An awareness of the
possibility of such surprises is essential to physi-
cians who do inguinal operations in pediatric age
groups.

The following instances of unexpected pathologic
conditions are drawn from the author’s practice and

Submitted March 2, 1962.

TABLE 1. — "Lumps” in the Groin in Children

Differential Diagnosis

Congenital

Hernia

Indirect

Complete

Incomplete

Sliding

Male: cecum, appendix, sigmoid
Female: tube, ovary, uterus
Littre

Pseudo-hermaphrodite

Hydrocele

Tunica vaginalis

Encysted, of the cord (Processus vaginalis)
Canal of Nuck
Cryptorchidism
Unilateral
Bilateral
Ectopic spleen
Ectopic adrenal
Diverticulum of the bladder

Acquired
Direct hernia
Femoral hernia
Richter’s hernia
Torsion
Testicle

Appendix testis
Ovary

Incarceration

Inflammatory
Inguinal adenitis
Primary
Secondary

Cat scratch, etc.

Adenitis of Cloquet’s node
Suppurative iliac adenitis

• In surgical operations in the inguinal area in
infants anti children many unusual pathologic
states were observed that were at first thought to
be simple hernia. Among the conditions ob-
served, in addition to complicated hernias and
other anomalies of the processus vaginalis, were
male pseudo-hermaphroditism, ectopic spleen,
ectopic adrenal with neuroblastoma, diverticu-
lum of the bladder, inguinal adenitis and sup-
purative iliac adenitis.

In light of the sometimes surprising contents
of the hernia sac, good exposure and careful
identification of all anatomic structures is man-
datory.

from his experiences and that of other surgeons in
a large children’s hospital.

“Lumps” in the groin in children are classified in
Table 1 for the purpose of differential diagnosis.

CONGENITAL "LUMPS"

The first unusual situation involving congenital
hernias concerns sliding hernia in the male. The
first step is to make the incision longer than that
routinely used for exposure. Frequently only a small
sliding element is present and the reconstruction of
a 360° peritoneal circumference at the internal ring
can be accomplished without a counter incision.
If the hernia is large and the anatomic features are
hard to identify, a La Roque maneuver, such as is
used in adults can be used quite satisfactorily. Un-
less good exposure is accomplished, there is hazard
of inadvertent removal of tissue that is not a part
of the hernial sac.

Quite common in infant girls is the finding of an
ovary, a tube or the uterus sliding into the neck of
the hernial sac. Dealing with such a situation can he
somewhat perplexing, for considerable bleeding is
entailed in dissection of the medial aspect of the
sac and the blood supply to the tube and ovary is
endangered. Also, since the procedure leaves these
structures hanging free within the peritoneal cavity,
torsion may occur. A useful technique for recon-
struction of the neck of the peritoneal sac is that of
Goldstein and Potts,1 in which the broad ligament,
tube and ovary are inverted and the internal ring
is closed, leaving the adnexal attachments and
avoiding the dissection in the broad ligament.

VOL. 97, NO. 2 • AUGUST 1962

The Littre hernia, in which the sac contains Meck-
el’s diverticulum, should be dealt with in the same
manner as any hernia in which tissue that ought not
be removed is incarcerated in the hernial sac — by
careful identification and separation before repair is
carried out. If treatment of the diverticulum is
necessary, a secondary incision should be made
lest the inguinal area become contaminated.

In one case in which an ovary apparently was
involved in the material incarcerated in a hernial
sac, closer inspection brought doubt as to the iden-
tity of the tissue and a pathologist who examined
a frozen section diagnosed “testicle.” The immediate
course in such circumstances is to determine the
character of the opposite gonad and the presence or
absence of a uterus. If a second testicle is found,
and there is no semblance of external male genitalia,
both testicles are removed. A biopsy specimen of
skin is taken for chromasomal determination of
sex. Examination of buccal smears is done later.
The male pseudo-hermaphrodite will fare better as
an infertile female than as a male without external
genitalia.

The rarest of hydroceles is that of the canal of
Nuck. It is analogous to the encysted hydrocele of
the processus vaginalis of the male. Lesions of this
kind may not be discernible by transillumination,
for often they are beneath the external oblique fas-
cia. They may be palpable as fixed, firm fusiform,
non-tender masses. Deep palpation may show them
to be separate from the internal ring, which helps
to distinguish them from hernia. For surgical ex-
posure, the same kind of incision that is used for
repair of hernia is used.

Cryptorchidism seems to predispose the testicle
to torsion, which calls attention to the condition.
At the time operation for relief of torsion is done,
the opposite undescended testicle may be drawn
down and anchored. The twisted testicle is never
sacrificed.

The embryologic development of the spleen and
the gonad from about the same area near the uro-
genital ridge explains why accessory spleens are
found in the scrotum and along the path of the
processus vaginalis. These abnormalities are easily
recognized and managed by routine procedure.

Ectopically placed adrenal tissue of the inguinal
area is also easily explained as the result of residual
remnants of primitive cells developing in the path
of the testicle and processus vaginalis.

ACQUIRED "LUMPS"

Although rare, a direct hernia sometimes is ob-
served in an infant or child. In the cases I have dealt
with, these lesions caused symptoms and at opera-
tion a defect in the floor of the canal medial to the
epigastric vessels was noted. Repair is by simple
imbrication of the transversalis fascia.

Femoral hernia in infants, also rare, is best man-
aged by a McVay Cooper’s ligament repair and
anatomic reconstruction of the abdominal wall.

The problems of incarceration include Richter’s
hernia and differentiation between torsion of the
appendix, a testicle or an ovary, and the ruling out
of an inflammatory process. While the preoperative
diagnosis is frequently correct, usually there can be
no certainty without surgical exposure.

INFLAMMATORY LUMPS

The inguinal canal is generally quite free of
lymph nodes, but occasionally the node of Cloquet,
which is the highest in the femoral area and nor-
mally lies behind Poupart’s ligament, may be in-
volved in the inguinal canal at or just behind the
internal ring. The tumors caused by involvement
of this kind are usually deep and painful and are
difficult to differentiate from incarcerated hernia or
perhaps even from incarcerated interstitial hernia
as seen in adults. Involvement of this node at the
internal ring has been observed secondary to in-
fantile vaginitis, to pustular diaper rash, to cat
scratch disease and to inflammation of the toes.

Although a considerable problem when it does
occur suppurative iliac adenitis is rare nowadays.
In one such case, inguinal drainage was necessary,
then retroperitoneal drainage of a higher abscess
four months later, and drainage of a metastatic ab-
scess of the omentum at the flexure six months
after that.

5353 Balboa Boulevard, Encino.

REFERENCES

1. Goldstein, R. I., and Rotts, W. J.: Inguinal hernia in
female infants and children, Ann. Surg., 148:819-822, 1958.

2. Gross, R. E. : The Surgery of Infancy and Childhood,
W. B. Saunders Co., Philadelphia, 1953.

3. Potts, W. J., Riker, W. L., and Lewis, J. E.: The treat-
ment of inguinal hernia in infants and children, Ann. Surg.,
132:566-567, 1950.

CALIFORNIA MEDICINE

Further Study of Spastic Dysphonia

BERNARD A. LANDES, Ph.D., Long Beach

The literature dealing with disorders of voice
contains little on the problem of spastic dysphonia,8
although this unusual condition was described at
least as early as 1871. 1 Usually the first symptom of
this disorder is frequent, uncontrollable, unpredict-
able hoarseness that sounds as if the vocal cord
adductors have suddenly gone into spasm. Except
for these episodes the voice remains relatively
normal. In some cases the abrupt transition from
normal voice to spastic voice is quite dramatic; in
other cases the difference is less pronounced because
even the “good” voice is impaired. A significant
diagnostic clue is, therefore, a voice which periodi-
cally changes in quality, either from “good” to
“bad” or from “bad” to “worse.” These spastic
episodes may be momentary or they may last for
several minutes.

Some of the few comments in the literature on
this condition have been summarized previously.7
The views of Glushak,2 Greene,5 Morrison,10 and
Staton11 are in general agreement that the condition
is not organically based, although these investigators
disagree somewhat in their views of the mechanics
of the spasm. In addition, several observers2,3'4,9
have pointed out the symptomatologic similarity be-
tween spastic dysphonia and stuttering.

In order to explore further the cause, the onset
and the clinical manifesations of spastic dysphonia,
as well as the appropriate therapy, additional cases
have been studied in detail.

Procedure

Nine adults with spastic dysphonia (seven women,
two men) ranging in age from 20 to 59 years, with
a median age of 34 years, were observed by the
author during the period 1957-60. The patients
were examined by a laryngologist, and, when
feasible, by a psychiatrist or psychologist or other
medical specialist for a coordination and corrobora-
tion of the diagnosis. Emotional factors preceding
the onset were explored thoroughly. When the clini-
cians involved were in agreement that the symptoms
should be categorized as spastic dysphonia, a reg-
imen of therapy, somewhat different from patient
to patient, was attempted.

The author is assistant professor of speech at Long Beach ( Cali-
fornia) State College. This article is based upon a paper presented at
the 1961 convention of the American Speech and Hearing Association
held in Chicago.

Submitted February 13, 1962.

• Seven women and two men with spastic dys-
phonia, ranging in age from 20 to 59 years,
were studied to determine the cause and the
means of development of the condition. The
patients were examined ljy a laryngologist and,
when feasible, by a psychiatrist or other medi-
cal specialist for coordination and corroboration
of the diagnosis. Psychiatric observations were
significant. A background of conflict with a par-
ent or spouse was frequent and typical. In almost
every case there were deep guilt feelings asso-
ciated with something the patient had said to the
person with whom he was in conflict. Similari-
ties with the psychic elements in these cases and
in cases of stuttering were noted. The results of
vocal reeducation and psychotherapy together
were comparatively successful. Hypnosis and
the use of tranquilizing drugs did not help.

Results

Two illustrative cases were described in a pre-
liminary publication.7 In addition, the following
case summaries are presented to show the similar-
ities encountered.

Case 1. A married woman, 20 years of age, was
referred by an instructor from whom she had re-
cently taken a course in public speaking. During
the initial interview, the student reported that her
voice was sometimes good and sometimes had, and
that onset of the difficulty had been some four years
before. She could not recall that the onset had
been related to any particular event. Ultimately the
following facts were obtained: At the time of the
initial consultation regarding the voice problem,
the patient was being treated by a gynecologist for
dyspareunia which made coitus difficult, painful
and at times impossible. She also had severe menor-
rhalgia. Further interviewing revealed that at age
15 the girl had dated a boy of whom she had be-
come very fond. This relationship progressed to the
point of coitus which was not culminated because
of her sudden fear. She told the hoy that she could
not carry on, that the nature of their relationship
must change. This pronouncement resulted in a
cessation of the relationship completely, for the
consequences of which the patient later expressed
regret. She met her present husband shortly after
that experience and eventually married him. She
later remembered that the onset of spastic dysphonia
coincided with this period of breaking with the
one boy friend and meeting the other. It was the

VOL. 97. NO. 2 • AUGUST 1962

opinion of the gynecologist, the speech pathologist
and the psychiatrist who saw the patient that the
spastic dysphonia and dyspareunia were related in
that the psychological mechanisms could have been
the result of the patient’s having said something
which, she felt, changed the course of her life (she
expressed regret at having married the second boy
rather than the first whom she could have married
had she not said certain things at a critical point
in their relationship). Because the trauma involved
both speech and sexual relations, the psychological
punishment involved both areas. Eventually the
patient acepted this diagnosis and through a com-
bined therapy program consisting of counseling,
voice retraining and medication positive results
were obtained. Voice returned to normal and sexual
relations were resumed without pain.

Case 2. A 47-year-old widow consulted the author
because of intermittent hoarseness of five years’
duration. Six years before the interview the patient
had insisted that her husband go to a physician for
a general physical examination. At first lie resisted
this invitation but after a long verbal battle he
consented. A malignant lesion was diagnosed which
several months later caused the husband’s death.
The widow returned to college, obtained a teaching
credential and began teaching in order to finance
her son’s education. She overtly disliked teaching.
In a few months, aberrations of voice were noticed.
Psychiatric consultation corrobated the opinion that
the mechanism at work was one of self-punishment:
the patient was placed in a position of having to
use her voice professionally in a role that perhaps
would not have been necessary if she had not previ-
ously used this same voice to insist upon her hus-
band’s medical examination. Voice therapy with the
patient under hypnosis did not help and the patient
did not return after the sixth session.

Other representative cases are presented in less
detail to illustrate further significant areas of
concern :

Case 3. A 25-year-old man who had stuttered
as a child had a cessation of stuttering sometime
during high school. Dysphonia then appeared almost
immediately. Elpon examination the voice was heard
to be essentially normal in quality except for
intermittent hoarseness accompanied by lip tremors.
The patient did not return for therapy after the
initial interview.

Case 4. A woman 59 years of age had hoarseness
typical of spastic dysphonia. Periodically a tremor-
like quality would develop in addition to the hoarse-
ness. Significant in the history was the fact that
five years before she sought advice about her voice
the patient discovered her husband dead in his

bedroom as a result of coronary artery disease. She
reportedly “went all to pieces” upon making this
discovery and simply sat on the edge of the bed
in a stupor. Even though she was repeatedly assured
by her husband’s cardiologist that no action at the
time could have prevented his death, she continued
to express guilt in not having called an ambulance
or physician immediately. Four years after her hus-
band’s death, her mother died after a long illness.
The patient admitted that she had never loved her
mother, had spoken harshly to her throughout the
illness, and after the mother’s death felt guilty for
having done so. Vocal symptoms began soon after
the mother’s funeral. The voice eventually returned
to normal after a regimen of psychologic counseling
coupled with voice retraining.

Case 5. The patient was a 23-year-old woman
who had worked as a telephone operator in a small
town for several years after graduating from high
school, then, encouraged by her success in that
position, had transferred to the telephone office in
a larger metropolitan area. Her reaction to the
change was one of almost immediate regret and
unhappiness, hut she felt that she could not return
to her small town and admit failure. A few months
after the transfer her voice began intermittently
to drop suddenly in pitch and assume a very hoarse
quality. This voice disorder necessitated her trans-
ferring from the telephone office to another job
which she disliked. Voice retraining along with
minimal psychological counseling returned the voice
almost to normal, but with occasional reversions
under stress.

Case 6. A woman of 35 years had graduated
from college with a degree in music. Before she
had an opportunity to sing professionally, she mar-
ried and began having a family. After her children
were school age, she became active in local singing
groups, devoting more and more of her time to
singing activities and less and less time to her
family. Her husband openly resented this encroach-
ment on family time. Symptoms of spastic dysphonia
began shortly after the husband began voicing his
objections, thereby forcing the patient to abandon
her musical pursuits. Short term, intensive (daily)
voice retraining, along with prolonged marital coun-
seling, achieved satisfactory results.

Case 7. A woman 44 years of age was observed
because of “voice tremor” of eight months’ dura-
tion. Although the acoustic effect was typical of
spastic dysphonia, the patient would not contribute
any information regarding her history (except in
innocuous detail) and would not accept furthur
referral. Voice retraining alone, and later under
hypnosis, did not yield satisfactory results.

CALIFORNIA MEDICINE

DISCUSSION

In none of the foregoing cases did laryngological
examination show evidence of an organic cause.
Frequently edema of the vocal cords was noted,
hut according to the examining laryngologists, it
was the result rather than the cause of the vocal
symptoms. Furthermore, although the history was
more dramatic in some cases than in others, there
seemed to be a common thread running through
most of them — frequently a history of guilt result-
ing from something the patient had said or failed
to say, or guilt resulting from the use of the voice.

It has been observed that patients with spastic
dysphonia typically have an increase in difficulty
when speaking over the telephone, when speaking
to strangers and when speaking to authority figures,
and less difficulty when speaking to small children
or pets or when reading in unison with others. The
similarity in this respect between the symptoms of
spastic dysphonia and those of stuttering, as has
been pointed out by other observers, 2’3,4’9 cannot
be lightly overlooked.

In terms of therapy, various approaches were
attempted with the above patients. Therapy under
hypnosis did not help in either of the two cases
in which it was used. In one case tranquilizing drugs
were prescribed on an experimental basis by the
physician but without success. Voice retraining
alone was not satisfactory. The only satisfactory
results obtained in any case came when adjustment
counseling, either psychiatric or psychologic, was
used along with voice therapy, thus pointing further
to the psychogenic basis of the disorder. This ob-
servation is consistent with similar ones by Arnold1
and Heaver.6

The successful regimen of voice therapy made
use of Froeschel’s “chewing method”13 for vocal

relaxation and ease of initiation of phonation.
Furthermore, faulty breathing patterns such as
antagonistic or too shallow breathing were noted
in most of the cases herein reported. Faulty pat-
terns were reported previously by Supacek and
Lacina12 and are apparently a frequent concomitant
of spastic dysphonia. Voice therapy, therefore, re-
quired re-education of breathing patterns along with
vocal relaxation, ease in initiation of phonation,
and psychological support to coordinate the efforts
of the several clinicians involved in each case.

Long Beach State College, 6101 East Seventh Street, Long Beach 4.

REFERENCES

1. Arnold, G. E.: Spastic dysphonia: I. Changing inter-
pretations of a persistent affliction, Logos, 2:3, 1959.

2. Glushak, L. : Dysphonia spastica (spastic hoarseness),
Laryngoscope, St. Louis, 38:273, 1928.

3. Greene, J. S. : Dysphemia and dysphonia, A.M.A. Arch.
Otolaryng., 26:74, 1937.

4. Greene, J. S.: Psychiatric therapy in dysphemia and

dysphonia: stuttering, psychophonasthenia, aphonia, fal-

setto, Ann. Otol., etc., St. Louis, 47:615, 1938.

5. Greene, M. C. L.: The Voice and Its Disorders, The
Macmillan Co., New York, 1959.

6. Heaver, L.: Spastic dysphonia: II. Psychiatric con-
siderations. Logos, 2:15, 1959.

7. Landes, B. A.: On the clinical nature of spastic dys-
phonia, Southern Speech J., 25:141, 1959.

8. Landes, B. A.: Selected bibliography on voice disor-
ders, J. Speech, Hearing Dis., 24:285, 1959.

9. MacMahon, C.: The treatment of dysphonia and allied
conditions, J. Laryngol., 54:343, 1939.

10. Morrison, W. W.: Diseases of the Ear, Nose, and
Throat, Appleton-Century-Crofts, New York, 1955.

11. Staton, D. E., Dysphonia and aphonia, Mississippi
Doctor, 17 :427, 1940.

12. Supacek, I., and Lacina, A.: Pneumographic findings
in cases of hyperkinetic and spastic dysphonia, Logos, 4:19,
1961.

13. Weiss, D. A., and Beebe, H. H. : The Chewing Ap-
proach in Speech and Voice Therapy, S. Karger Publishers,
New York, 1951.

VOL. 97

2 • AUGUST 1962

CASE

Rupture of Abdominal Aortic Aneurysms
Complicated by Acute Renal Failure
And Aspergillosis

H. VERNON FREIDELL. M.D., and
WILLIAM F. GEBHART, M.D., Santa Barbara

The recent occurrence of two cases of rupture
of an abdominal aortic aneurysm, successfully re-
sected, followed by acute renal failure with sur-
vival prompted a review of this combination. The
occurrence of aspergillosis causing anuria by ure-
teral obstruction in one of the cases is documented.

Cottage Hospital is a general hospital with 237
beds. In the five-year period from 1957 through
1961, there were 44,748 admissions which included
nine cases of ruptured abdominal aortic aneurysm.
The average age of the patients with this lesion was
66 years. All were males and the symptoms of the
rupture had been present for an average of 22
hours. In those who died without operation, death
occurred within 16 hours of admission. Four of the
nine patients were operated upon and two survived.

Following are reports of the cases of the two
who lived.

Case 1. A 79-year-old white man was admitted
to the Cottage Hospital emergency room April 5,
1961. with chief complaint of cramping in the
left lower quadrant of the abdomen for one week.
On examination blood pressure was 200/112 mm.
of mercury and the pulse rate was 80. There was
a grade 2 murmur of aortic stenosis. A rounded
mass about three inches in diameter, with a “trans-
mitted pulsation,” was palpated in the left lower
quadrant of the abdomen. Ninety minutes after ad-
mission the patient suddenly developed profound
shock while in the x-ray department. In a kidney-
ureter-bladder film a large aneurysm with calcifi-
cation in the wall was visualized. At operation a
large retroperitoneal hematoma was noted, with
rupture of the abdominal aneurysm, which extended
from the level of the renal veins superiorly to the
inguinal ligament inferiorly. A Teflon® Y tube was
used to replace the diseased segment of aorta, the
aorta having been clamped below the renal arteries
for a period of 3 hours and 15 minutes while the

Submitted March 2, 1962.

From the Santa Barbara Cottage Hospital, Santa Barbara.

procedure was carried out. During the surgical pro-
cedure the patient received 15 units of whole blood.

The patient was oliguric from the time of arrival
in the intensive care unit. The urine had a specific
gravity of 1.005 and showed 1 plus albumin and
numerous granular casts. Oliguria continued (50-
60 cc. of urine daily) for a total of six days. Dur-
ing that time appropriate intravenous therapy, rigid
fluid restriction, general supportive measures and
administration of potassium ion exchange resins
were carried out. Although the nonprotein nitrogen
rose to 132 mg. per 100 cc. and mild metabolic aci-
dosis developed, the patient’s general condition did
not deteriorate to the point of requiring extracor-
poreal hemodialysis.

On the sixth postoperative day urine volume be-
gan to increase (350 cc. in 24 hours) and by the
tenth postoperative day the patient was well into
the diuretic phase of acute tubular necrosis. Twenty-
five days later the non-protein nitrogen was 46 mg.
per 100 cc. and other chemical components of the
blood were within normal limits. A moderately
heavy growth of E. coli developed on a culture of
the urine, but after therapy with AzoGantrisin®*
and Mandelamine (methanamine mandelate) the
urine culture was sterile.

Case 2. The patient, a 65-year-old white man,
was admitted to the Santa Barbara Cottage Hospital
at 6 a.m. September 17, 1961. He was known to
have had essential hypertension since 1954. Recent
treatment had included Rauwiloid® (alseroxylin) ,
2 mg. twice a day; Inversine® (mecamylamine) ,
2.5 mg. each evening; and Diuril® (chlorothiazide),
500 mg. each morning. The morning of admission
the patient had pain of sudden onset in the left
upper quadrant of the abdomen with radiation to
the flank area, the left lower quadrant and the left
groin, accompanied by nausea without vomiting.

The patient was pale and perspiring. The blood
pressure was 180/110 mm. of mercury and pulse
rate 80. A firm mass with transmitted pulsation was
palpable in the left lower quadrant of the abdomen.
Pulsations were present in the lower extremities at
this time.

At operation, done under hypothermia at 31° C.,
an aneurysm of the aorta, 15 cm. x 10 cm., was
found to be ruptured. The aneurysm extended to

*Sulfasoxazole with phenylazo-diamino-pyridine hydrochloride.

CALIFORNIA MEDICINE

within 0.5 cm. of the renal arteries, necessitating
clamping of the aorta above the origin of the renal
arteries. During the procedure, which took seven
and a half hours, the aorta was clamped for two
hours and thirteen minutes, and the patient received
13 units of whole blood. Because of the involvement
of the left renal artery and vein, it was necessary to
remove the left kidney (the pathologist reported it
arteriosclerotic) .

The patient was oliguric on his return to the in-
tensive care unit. A “radioactive renogram” was
done on the right side to ascertain whether the oli-
guria was due to right renal artery occlusion with
infarction of the kidney, or due to tubular necrosis.
A normal “vascular spike” was obtained, confirm-
ing the diagnosis of tubular necrosis.

Azotemia and hyperpotassemia progressed rap-
idly during the early phase of oliguria, and the
patient’s general clinical status deteriorated. On the
fourth day extracorporeal hemodialysis was carried
out with a Travenol® twin coil kidney for a period
of six hours, and his clinical condition then greatly
improved. In spite of conservative medical manage-
ment with appropriate fluid restriction and ion ex-
change resins for control of serum potassium levels,
acidosis, azotemia, and hyperpotassemia increased
and, on the tenth day of renal shut-down, extracor-
poreal hemodialysis again was carried out for six
hours. Appropriate medical management was con-
tinued, and by the sixteenth postoperative day urine
output had increased to 620 cc. in 24 hours.

From the seventeenth postoperative day the pa-
tient entered the diuretic phase. Adequate fluid and
electrolyte replacement was maintained and the clin-
ical condition of the patient improved as azotemia
diminished. Because of complicating tracheobron-
chial and lower urinary tract infections occurring
within three weeks of operation, the patient re-
ceived chloramphenicol for five days, terramycin
for five days, and streptomycin every other day for
five injections.

Approximately a month after the second dialysis
the patient suddenly became anuric. Urological con-
sultation was obtained, and at cystoscopic examina-
tion a large 0.75 cm. x 0.5 cm. plug of “whitish
tissue” was noted to be occluding the lower right
ureter. It was removed and a retrograde pyelogram
then revealed no evidence of abnormality. Urine
volume immediately increased, and the patient’s
general clinical condition progressed satisfactorily.
By microscopic analysis and bacteriologic study the
plug of material removed at cystoscopy was found
to be Aspergillus fumigatus.

DISCUSSION

Rupture of the lesion is one of the more frequent
causes of death in patients with arteriosclerotic ab-
dominal aneurysm.20,30 It has been calculated that
2,450 people die of it each year in the United
States.5

There is usually a period of hours to days be-
tween rupture and death. Owing to the retroperi-

toneal position of the aorta, the initial blood loss
from the vessel is usually confined by the peritoneal
surface, and it is not until the peritoneum ruptures
that death occurs.8 Before aortic resection and graft
replacement was surgically feasible, rupture of the
aneurysm was fatal. Now, with operation, 50 to 60
per cent of patients survive.13,15

Acute renal failure is a frequent and often fatal
complication of operation on the aorta, causing
death in 10 to 60 per cent of reported series. The
exact pathogenesis of renal failure is not known,
but some of the factors are atherosclerosis, shock,
transfusions, hydration of patients, reflex renal
vasospasm, and the location and duration of aortic
cross-clamping.* It is becoming apparent that the
more important features are reflex renal vasospasm
and renal ischemia from cross-clamping.

How long the flow of blood to the kidneys can
be occluded without producing irreversible ischemic
changes in them is not known. It was shown in ani-
mals that when both the suprarenal aorta and renal
arteries were clamped for from two to three hours,
severe renal damage resulted. When only the supra-
renal aorta was occluded for the same period of
time much less damage occurred, suggesting a col-
lateral flow through the renal capsule.23,24 It has
been found in patients with normal kidneys that
occlusion of the suprarenal aorta for periods greater
than 30 to 40 minutes may result in renal failure,
whereas infrarenal aortic occlusion of 1 to 2 hours
may be tolerated safely. Hypothermia does not per
se produce any residual damage to the kidneys; it
lowers tissue metabolism to a point at which renal
ischemia for a prolonged period may not result in
irreversible renal damage. Hypothermia to 27° C.
doubled the period for which arterial occlusion
could be maintained without severe renal damage.
It results in decrease of blood pressure with reduced
glomerular filtration fraction, but without the asso-
ciated decreased urinary volume or significant de-
crease in sodium excretion that usually occurs in
normothermic conditions following any procedure
that reduces glomerular filtration rate.21 As delivery
of oxygen depends not only on the flow of blood
but also on the state of the vascular bed in the kid-
neys, the addition of ganglionic blockade by opera-
tion or by sympatholytic drugs helps prevent renal
vasospasm, increase vascular resistance and reduce
the severity of renal damage.22,24'29,31

It has been suggested that administration of Man-
nitol® (a hexahydric alcohol) is a safe effective way
of preventing acute functional renal failure.4 It is a
small particle that is slow to equalize with the extra-
vascular compartments after an intravenous infusion.
As it is filtered at the renal glomerulus and non-reab-
sorbable from the tubular lumen, it results in osmotic
diuresis. The method used by Barry and coworkers4
was to infuse it as a 20 per cent solution at a rate of
5.5 cc. per minute during aneurysmectomy until the
free flow of blood was reestablished. If. after opera-
tion, the urine excretion fell to below 60 cc. per hour

•References Nos. 2, 10, 12, 14, 16, 18, 22, 27, 31.

VOL. 97, NO. 2 • AUGUST 1962

for two successive hours, booster doses of 12.5 gm. of
Mannitol® were given intravenously over a three-
minute period and thereafter the agent was added
to each bottle of intravenous fluid as needed to
maintain a urinary flow of 60 to 120 cc. per hour.

Severe oliguria is usually preceded by a depres-
sion of the renal blood flow and glomerular filtra-
tion rate. Clinical studies3 showed that Mannitol
infusions increase the renal blood flow, the glomeru-
lar filtration rate and the urinary flow. It was also
observed that the rate of urinary flow varies directly
with the renal blood flow and the glomerular filtra-
tion rate. The plasma expansion resulting from use of
Mannitol® is determined by the total quantity of the
agent infused, the rate of infusion, and the rate at
which it leaves the vascular compartments.3 In an
oliguric patient the recommended test dose of 12.5
gm. of Mannitol® is given in a three-minute interval.
If a satisfactory response is obtained, 30 cc. per
hour during the ensuing three hours is infused.
Thereafter enough Mannitol is used to maintain a
urinary flow of 60 to 120 cc. per hour until the
danger of renal failure has passed.

The severity of renal failure following aortic op-
erations is variable, as was shown in Cases 1 and 2
reported herein. In Case 2 the renogram permitted
differentiation between renal artery occlusion and
acute tubular necrosis in the remaining kidney as
the cause of the anuria. The renogram showed an
adequate initial vascular spike representing renal
vascular capacity that would have been absent had
the renal artery been occluded.1,32

Anuria occurring during the diuretic phase sec-
ondary to ureteral blockage by a ball of Aspergillus
fumigatus has not been described in the literature
before. The presence of balls of Candida albicans
in the bladder has been reported and there is one
report of Candida blocking a ureter in a case of dis-
seminated fungous disease.6,11,28 Aspergillus, a
mold, is a frequent laboratory contaminant and not
a common pathogen of man. The manifestations are
protean and depend on the organ involved. Lungs,
skin, eyes, ears, bronchi, nails, bone and meninges
have all been involved.9,17,19,25,26 Aspergillosis usu-
ally occurs in patients who are chronically ill and
who have received antibiotics and steroids. These
agents alter or suppress the resistance to Aspergillus
fumigatus and allow it to become clinically impor-
tant. In Case 2 the patient had received chloram-
phenicol, terramycin and streptomycin. The finding
of this ball of Aspergillus fumigatus was the only
indication of this condition present in this patient,
and whether or not parenchymal damage secondary
to this fungus may appear in the future is not clear
at this time. At present there is no indication of
dlinically significant aspergillosis.

SUMMARY

Two patients who had rupture of an abdominal
aortic aneurysm and then acute renal failure fol-
lowing aortic resection have been reported. One

patient, after having the infrarenal aorta clamped
for 3 hours and 15 minutes, had clinical uremia
which responded to conservative management. In
the other patient the operation was performed un-
der hypothermia of 31° C. and the suprarenal aorta
was clamped for 2 hours and 13 minutes. One kid-
ney was removed and tubular necrosis developed in
the other. In the diuretic phase the patient had
ureteral obstruction caused by a ball of Aspergillus
fumigatus. The decision to treat this patient as
having acute tubular necrosis rather than renal ar-
tery occlusion following the aortic operation was
based on information supplied by a renogram with
radioactive material.

Section of Internal Medicine, The Santa Barbara Medical Clinic,
1421 State Street, Santa Barbara (Gebhart).

REFERENCES

1. Abt, A. F., Balkus, V. A.: The radio-renogram with
rodio-renografin-D31 as a diagnostic aid in urological prob-
lems, J. of Urol., Vol 85 #1:95, 1961.

2. Bahnson, H. T. : Treatment of abdominal aortic aneu-
rysm by excision and replacement by homograft, Circula-
tion, 9:494, 1954.

3. Barry, K. G., Berman, A. R.: The acute effect of the

I. V. infusion of Mannitol on blood and plasma volumes,
N.E.J.M., 264:1085, 1961.

4. Barry, K. G., Cohen, A., Knockel, J. P., Whelan, T. J.,
Beisel, W. R., Vargas, C. A., LeBlanc, P. C., Jr.: The pre-
vention of acute functional renal failure during resection
of an aneurysm of the abdominal aorta, N.E.J.M., 264:967,
1961.

5. Burch, G. E., DePasquale, N.: Study of incidents of
abdominal aortic aneurysms in New Orleans, J.A.M.A.,
172: #18 81/2011, 1960.

6. Chesholm, E. R., Hutch, J. S.: Fungus ball (Candida
albicans) formation in the bladder, J. Urol., Vol. 86: #5,
Nov. 1961.

7. Cooley, D. A., DeBakey, M. E.: Ruptured aneurysms
of abdominal aorta excision and hemograft replacement,
Post Graduate Medicine, 16:334, 1954.

8. Copping, G. A.: Spontaneous rupture of abdominal
aorta, J.A.M.A., 151 :374, 1953.

9. Cowley, E. P.: Aspergillosis and the Aspergilli, Arch.
Int. Med., Vol. 80 #4:423, 1947.

10. Creech, O., DeBakey, M. E., Morris, G. C., Mayer,

J. H.: Experimental and clinical observation on the effects
of renal ischemia, Surgery, 40:129, 1956.

11. Davis, J. B., Whitaker, J. D., Ding, L. K., Kiefer, J.
H.: Disseminated, fatal, postpartum candidiosis with renal
suppuration, J. Urol., 75:930, 1956.

12. DeBakey, M. E., Cooley, D. A.: Surgical considera-
tions of acquired disease of the aorta, Annals Surg., 139:
763, 1954.

13. DeBakey, M. E., Cooley, D. A., Creech, 0. Jr.: An-
eurysm of the aorta treated by resection, J.A.M.A., 163:
#16, 1439, 1957.

14. DeWeese, M. S., Fry, W. J.: Pitfalls in surgery of
abdominal aorta, The Surg. Clin, of N. A., 41, #5:1331,
Oct. 1961.

15. Doolan, P. D., Wiggins, R. A., Thiel, G. B., Lee, K.
S., Martinez, E.: Acute renal insufficiency following aortic
surgery, Am. J. Med., 28:895, 1960.

16. Dubost, C., Dubost, C. : Resections of aneurysms of
the aorta, Angiology, 5:261, 1954.

17. Finegold, S. M., Will, D., Murray, J. F. : Aspergil-
losis, Am. J. Med., Vol 27 :463, 1959.

18. Goldowsky, S. J.: Spontaneous rupture of abdominal
aorta, Rhode Island Med. J., 35:604, 1952.

CALIFORNIA MEDICINE

19. Grcevic, N., Matthews, W. F.: Pathologic changes in
acute disseminated aspergillosis, Am. J. Clin. Path., 32:
Part II, 536, 1959.

20. Javid, H., Dye, W. S., Grove, W. J., and Julian, 0. C.:
Resection of ruptured aneurysm of the abdominal aorta,
Ann. Surg., 142:613, 1955.

21. Mayer, J. H.: The effect of hypothermia on renal
function and renal damage from ischemia, Ann. N. Y. Acad.
Sci., 80:424, 1959.

22. Mayer, J. H., Heider, C., Morris, G. C. Jr., Handley,
C.: Renal failure: 1. The effect of complete renal artery
occlusion for variable periods of time as compared to ex-
posure to sub-filtration arterial pressures below 30 mm. Hg.
for similar periods, Ann. Surg., 145:41, 1957.

23. Mayer, J. H., Heider, C., Morris, G. C., Handley, C.:
Hypothermia III, the effect of hypothermia on renal damage
resulting from ischemia, Ann. Surg., 146:152, 1957.

24. Morris, G. C., Heider, C. F., Mayer, J. H.: The pro-
tective effect of subfiltration arterial pressure on the kidney,
Surg. Forum Amer. College Surg., 6:623, 1956.

25. Moss, E. S., McQuown, A. L. : Aspergillosis: Atlas of

Medical Mycology, Sec. Edition, 143, 1960, Williams &
Wilkins.

26. Peer, E. T.: Case of aspergillosis treated with Am-
photeracin B, Dis. of the Chest, 38:222, 1960.

27. Powers, S. R. Jr., Baba, A., Stein, A.: The mecha-
nism and prevention of distal tubular necrosis following
aneurysmectomy, Surgery, 42:156, 1957.

28. Raphael, S. S., Badgery, A. R.: A case of hydrone-
phrosis due to fungus ball, Canadian Med. J., 79:480, 1958.

29. Shikota, J., Kunkler, A. W., Shumecka, H. B., Nash,
F. D., Hubbard, J. D.: Renal denervation and survival fol-
lowing renal ischemia, Arch. Surg., 81 :747, 1960.

30. Sommerville, R. L., Allen, E. V., Edwards, J. E.:
Bland and infected arteriosclerotic abdominal aortic aneu-
rysm: A clinicopathological study, Medicine, 38:207, 1959.

31. Szelagiji, D. E., Smith, R. F., Whitcomb, John G.:
The kidney in surgery of the abdominal aorta, Arch. Surg.,
79:252, 1959.

32. Winter, C. C.: Kidney function in children, Calif.
Med., 94:127, March 1961.

VOL. 97, NO. 2 • AUGUST 1962

For information on preparation of manuscript,

see advertising page 2

DWIGHT L. WILBUR, M.D Editor

ROBERT F. EDWARDS . . . Assistant to the Editor

Policy Committee — Editorial Board

OMER W. WHEELER, M.D Riverside

SAMUEL R. SHERMAN, M.D San Francisco

CARL E. ANDERSON, M.D Santa Rosa

JAMES C. DOYLE, M.D Beverly Hills

MATTHEW N. HOSMER, M.D San Francisco

IVAN C. HERON, M.D ■ .... San Francisco

DWIGHT L. WILBUR, M.D San Francisco

EDITORIAL

The Next Step

Presidential hopes for enactment of the King-
Anderson Bill were sent into a tailspin last month
when the Senate, by a 52 to 48 vote, adopted a mo-
tion to table a proposal to tack this measure onto
an otherwise acceptable welfare bill.

Obviously many physicians took comfort from
the fact that for all practical purposes the issue of
King-Anderson is dead for the remainder of 1962.
So many doctors had followed the progress of the
campaign that in its terminal period there was great
satisfaction in the rallying of allied forces and the
decline of administrative optimism.

There remain two unfortunate aspects of this pro-
posal, both of which must be faced and dealt with.
First is the fact that medical care for the aged has
been turned into a political football. Second is the
fact that King-Anderson proposals will be reintro-
duced in the early days of 1963.

Coping with the business of political blandish-
ments to the aged will be extremely difficult. The
politician with an axe to grind and with easy access
to all media of communication can build an attrac-
tive proposal which is bound to appeal to a consid-
erable proportion of the 17 million voters of 65
years or older. Through such a proposal he can
promise immediate benefits to this large group and
future benefits to those less elderly.

Many incumbent members of Congress will use
this approach to the voters in the November elec-
tion. Likewise, many aspirants for Congressional
seats will use the care-for-the-aged approach in op-
position to incumbents who were on record as oppo-
nents of the social philosophy of the measure.

Thus in 52 instances, Senators who voted to table
the Senate bill will be haunted in their campaigns
for reelection, either this year or two or four years
hence.

Members of the House of Representatives, who
were spared the roll call vote, will not have the same
problems of reelection as the Senators, with the ex-

ception of a few outspoken opponents of King-
Anderson legislation who placed their philosophies
squarely before their constituents. Most members of
the lower house were content to walk a narrow line
and were doubtless happy that the issue was settled
in the Senate.

If the presidential statements relative to making
legislation of the King-Anderson type the prime
campaign issue in November are carried out, we
can expect any legislator who opposed this measure
to be charged with favoring neglect of care for the
aged.

As to the second residue, the fact that similar leg-
islation will he introduced in the new Congress next
January, much more of a constructive nature is
possible.

In the first place, the medical profession and its
allies have gained five months of time. During this
period, further progress will be made in implement-
ing the Kerr-Mills legislation already on the statute
books. Time is gained for further consideration of
implementing legislation in those states which have
not already acted in this direction. Time is gained
for improving implementing legislation in those
states where such legislation exists but may need
amending.

It is noteworthy that the California delegation to
the American Medical Association introduced a
resolution in June calling for (a) reaffirmation of
support of Kerr-Mills, (b) prompt consideration of
implementing legislation in those states which have
not yet acted in this direction, and (c) amendments
to legislation in those states where such amendments
may he indicated on the basis of experience. Where
state legislation to implement federal grants is re-
quired promptly, it is unavoidable that the programs
adopted by the various states will be of wide variety
and that some of the programs, enacted on an em-
pirical basis, will need revision. Where changes are
indicated by experience, they should be made.

In similar fashion, the five months gained at this
time will permit the Blue Shield plans and other vol-

CALIFORNIA MEDICINE

untary programs to expand their services and to
provide over-65 coverage for the growing number
of citizens in this age bracket.

Already several large insurance carriers have pro-
duced contracts designed to ease the financial bur-
den of illness for persons over 65. As time goes on
and experience accumulates, it is only reasonable to
assume that better coverage will be offered. Califor-
nia Physicians’ Service, one of the Blue Shield plans
which has experimented in this field, has already
come out with advanced coverage. Others are bound
to follow. When they do, experience teaches that the
public is better served through competition. The
laggard in the competitive race for coverage of more
people is the loser. The carriers willing to risk a lit-
tle more, within the bounds of sound business, will
be the gainers.

With an expansion in the coverage provided by
all carriers there will come a diminution of the need
and demand for governmental intervention. Govern-
ment has no place in the underwriting of insurance
unless and until private resources are proved to be
inadequate or inappropriate.

The medical profession and its allies have fought
a successful battle this year. However, the war still
goes on and the profession must keep on fighting.
While the fight so far has been characterized by

King-Anderson proponents as directed against a
plan for paying for hospital care out of the Social
Security fund, the implications of this type of legisla-
tion are much deeper. In essence, this is a fight
against the perversion of a welfare program into the
delivery of services, rather than dollars. If hospital
services are to be provided at the outset, medical
services would surely follow. From that point on,
any number of services might be added, for an end
result that would place a large group of elderly citi-
zens completely under the domination of the govern-
ment. At the same time, all purveyors of services
would be burdened with the same yoke.

Fortunately, a few months have been gained right
now for the production of something better. Right
now there is time to work on and for the develop-
ment of programs under the voluntary method
which will be superior to government programs and
thus negate their need.

Physicians who have fought the fight so far must
be encouraged to continue fighting. The little suc-
cess we have had this summer in the Senate cannot
for a moment be looked upon as a victory, but it
has shown us that we need not be without hope. We
have found out that when we are right about what
is wrong, we have surprising strength if we will use
it. Use it now we must.

^ r MEDICAL

ASSOCIATION

NOTICES & REPORTS

Transactions of the House of Delegates

San Francisco, April 14 to 18, 1962

Note: The following report of the transactions of the
House of Delegates of the California Medical Association
is selected and abridged. A complete transcript of all pro-
ceedings is on file in the Association office in San Fran-
cisco and available for the inspection of all members.

REFERENCE COMMITTEES

Committees appointed by Speaker James C. Doyle
at the first meeting of the House of Delegates Sat-
urday evening, April 14, were as follows:

Committee on Credentials: John Galgiani, San
Francisco, chairman. (In order to speed up regis-
tration two boards were appointed, one board to
deal with registration of the county delegations
starting with “A” through “L,” the other starting
with “M” and going through “Z” and also dealing
with registration of the Past Presidents and Coun-
cilors.)

A through L Board: Robert L. Blackmun, Los
Angeles; Robert M. Dorn, Beverly Hills; Horace
F. Sharrocks, Sebastopol; David J. New, Modesto;
Chester Tancredi, San Diego; Allen C. Mitchell,
Monterey.

The M through Z Board: John V. Pollack, Los
Angeles; Charlotte C. Baer, San Francisco; Wil-
liam T. Bender, San Francisco; Forrest M. Willett,
San Francisco; Edward J. Twigg, Alameda; Sidney
P. Mitchell, Santa Clara.

Reference Committee 1. (This committee reviews
the reports of the officers, the Council, the commis-
sions, and standing and special committees.) James

Yant, Sacramento, chairman; George Herzog, San
Francisco; Dudley Cobb, Jr., Los Angeles; Donald
Abbott, Riverside, alternate.

Reference Committee 2. (This committee on
finance reviews the reports of the secretary and ex-
ecutive secretary and studies and makes recom-
mendations to the House of Delegates on the budget
submitted by the Council and the amount of dues
for the ensuing year.) James J. Benn, Jr., Ripon,
chairman; Stanley Truman, Oakland: Ian Mac-

OMER W. WHEELER, M.D President

SAMUEL R. SHERMAN, M.D President-Elect

JAMES C. DOYLE, M.D Speaker

IVAN C. HERON, M.D Vice-Speaker

CARL E. ANDERSON, M.D. . . Chairman of the Council
BURT L. DAVIS, M.D. . . Vice-Chairman of the Council

MATTHEW N. HOSMER, M.D Secretary

DWIGHT L. WILBUR, M.D Editor

HOWARD HASSARD Executive Director

JOHN H UNTON Executive Secretary

General Office, 693 Sutter Street, San Francisco 2 • PRospect 6-9400

ED CLANCY Director of Public Relations

Southern California Office:

2975 Wilshire Boulevard, Los Angeles 5 • DUnkirk 5-2341

CALIFORNIA MEDICINE

donald, Los Angeles; Walter Carpenter, San Diego,
alternate.

Reference Committee 3. (This committee con-
siders new and miscellaneous business.) Don C.
Musser, San Francisco, chairman; Charles Grayson,
Sacramento; Harold B. Miles, Santa Barbara; Har-
old Kay, Oakland, alternate.

Reference Committee 3A. (To consider business
of Committee 3 when the volume becomes too great
for one committee to handle.) James W. Moore,
Ventura, chairman; William Argo, Fresno; Mal-
colm Watts, San Francisco; George Buehler, Whit-
tier, alternate.

Reference Committee 3B. (This committee also is
a supplement to 3 and 3A. ) James A. Spencer, Wat-
sonville, chairman; Roger C. Isenhour, San Diego;
Clyde Boice, Palo Alto; Donald R. Fitch, Glendale,
alternate.

Reference Committee 4. (This committee consid-
ers amendments to the Constitution and Bylaws.)
Frank C. Melone, Ontario, chairman; Walter H.
Brignoli, St. Helena; Luther Newhall, Santa Cruz;
Thomas E. Hanigan, Santa Ana, alternate.

Reference Committee on California Physicians’
Service. Seymour Strongin, Bakersfield, chairman;
William J. Newman, Sonoma; Henry Brown, San
Mateo; Samuel Gendel, Anaheim.

PRESENTATION OF FIFTY-YEAR AWARDS

Pins commemorative of 50 years of membership
in the California Medical Association have been pre-
sented to the following physicians:

John Lowe, Alameda-Contra Costa County

Clarence S. Compton, Kern County

L. D. Hollingsworth, Orange County

Harry 0. Hund, Marin County.

ill

STUDENT A.M.A. REPRESENTATIVES

The representatives from California medical
schools to the Student American Medical Associa-
tion were introduced:

From the University of California, San Francisco:
Carew Farrity, Robert Rock, and Robert Lumsden.

From Loma Linda U niversity School of Medicine:
John Hodgkin and Phil Lindsey.

From the University of Southern California
School of Medicine, Los Angeles: Harold Triplett
and Sam Balbum.

i i i

WOMAN S AUXILIARY

Mrs. Lawrence Custer, president of the Woman’s
Auxiliary, reported on the activities in her year of
tenure.

VOL. 97. NO. 2 • AUGUST 1962

ACTION ON RESOLUTIONS

The 1962 C.M.A. House of Delegates took action
on 91 resolutions in its regular session and ap-
proved one emergency resolution.

Shown below are all resolutions, in numerical
order, with a note on the action taken on each. The
subject of each resolution and the author are also
shown.

In several instances, reference committees con-
sidered two or more resolutions as a group and
took one action affecting all resolutions in the
group. Where such action was taken, reference is
made on the first-numbered resolution of the group
and following resolutions are referred back to the
earliest numbered.

Where resolutions were not favorably acted on,
the language of the resolution is not shown but the
subject matter, the author and the disposition are
shown.

/ i i

PENSIONS FOR SELF-EMPLOYED INDIVIDUALS

Resolution No. 1.

Author: L. P. Armanino.

Representing: San Joaquin Medical Society.

Whereas, self-employed individuals are presently
denied certain income tax benefits for retirement
plans that are granted to employees and officers cov-
ered by corporate pension plans; and

Whereas, efforts to obtain these benefits through
federal statute such as H.R. 10, known as the Keogh
Bill, appear to have little likelihood of success; and

Whereas, it is the considered opinion of experi-
enced tax attorneys that such benefits cannot law-
fully be obtained in California by professional
associations or partnerships under existing Califor-
nia statutes and regulations of the Internal Revenue
Service; now, therefore, be it

Resolved : That the House of Delegates of the
California Medical Association endorse the efforts
of the Commission on Professional Welfare and the
representatives of other professions in drafting and
supporting appropriate enabling state legislation to
authorize the formation of professional corpora-
tions; and be it further

Resolved : That nothing in such incorporation
procedure should affect or impair the professional
relationship between the patient and the physician
or change the laws, rules and regulations pertaining
to the practice of medicine by licensed persons, the
standards for professional conduct or disciplinary
and regulatory power of the Board of Medical Ex-
aminers and other established professional groups.

ACTION: Referred to Council, together with Reso-
lutions Nos. 5, 19, 45 and 62.

APPROVAL OF A.M.A. SUBCOMMITTEE REPORT
"MEDICAL CARE FOR EYE PATIENTS"

Resolution No. 2.

Author: James A. Spencer.

Representing: Santa Cruz Medical Society.

Whereas, California ophthalmologists and mem-
bers of the California Medical Eye Council and the
C.M.A. hereby affirm the important fact that the
A.M.A. House of Delegates adopted, in June of 1961,
the report of its subcommittee clearly defining the
relation of medicine to optometry; and

Whereas, these definitions of eye care have long
been needed, not only by ophthalmology but by
American medicine generally, to clear up the confu-
sion which still exists in the public mind as to the
distinction between medical eye care and optometric
services; and

Whereas, there has long been an increasing ten-
dency for optometry, functioning independently on
the periphery of medicine, to extend its scope of
activities and to assume functions which should be
exclusive to the physician, namely diagnosis and
even treatment of eye conditions; and

Whereas, (A.M.A. report quotes) “diseases lead-
ing to blindness may be present without symptoms
(and) have often escaped detection for lack of med-
ical examinations” (so that) “anything less than a
medical . . . eye . . . examination may jeopardize not
only the patient’s vision but his general health and
even his life; now, therefore, be it

Resolved : That this House of Delegates voice
its approval of the above-mentioned A.M.A. Sub-
committee Report on Relation of Medicine to Op-
tometry; and be it further

Resolved: That it be reaffirmed (as quoted by
the A.M.A. subcommittee) that “the public interest
requires that physicians (and the public) under-
stand the extent to which optometry’s position and
practices conflict with medical principles”; and be
it further

Resolved: That medicine recognize that there
can be no justification for considering as adequate
the management of ocular disease by anyone with
less training than that of the physician.

ACTION: Adopted by House.

i i 1

INDUSTRIAL ACCIDENT COMMISSION FEES

Resolution No. 3.

Author: Horace Sharrocks.

Representing: Sonoma County Medical Society.

Whereas, there is an official minimum med-
ical fee schedule, for services rendered under

CALIFORNIA MEDICINE

the California Workmen’s Compensation Laws, as
adopted by the Industrial Accident Commission of
the State of California in 1954 and amended in 1957
and 1959; and

Whereas, this schedule does not reflect changes
in the practice of medicine and the development of
new procedures and phases of medical practice; and

Whereas, the 1960 Relative Value Studies as
adopted by the California Medical Association Coun-
cil does reflect these changes; now, therefore, be it

Resolved : That the California Medical Associa-
tion through its appropriate committee, recommend
to the Industrial Accident Commission of the State
of California the adoption of this Relative Value
Studies with a minimum unit value of five dollars.

ACTION : Referred to Committee on Fees.

i i i

CENSURE OF A.C.S. SPOKESMAN

Resolution No. 4.

Author: Robert B. Smalley.

Representing: Mendocino-Lake County.

ACTION : Not adopted by House.

1 1 i

CORPORATE PRACTICE OF MEDICINE

Resolution No. 5.

Author: Roger C. Isenhour.

Representing: San Diego County Medical Society.

Whereas, there has been a steadily increasing
number of physicians who have associated in the
practice of medicine with an enormous increase in
business complexities; and

Whereas, the incidents of corporate form of busi-
ness are frequently fundamental in a sound business
organization and are necessary to promote the nor-
mal course of persons associated together in busi-
ness, and

Whereas, it is fundamental that physicians
should not be discriminated against in their choice
of business entity as long as the personal doctor-
patient relationship is not endangered; now, there-
fore, be it

Resolved: That the House of Delegates of the
California Medical Association endorse the efforts
of the Commission on Professional Welfare and the
representatives of other professions in drafting and
supporting appropriate enabling state legislation to
authorize the formation of professional corpora-
tions; and be it further

plinary and regulatory power of the Board of Medi-
cal Examiners and other established professional
groups.

ACTION: Referred to Council ; see Resolution No. 1.

i 1 i

CORPORATE PRACTICE OF MEDICINE

Resolution No. 6.

Author: William F. Quinn.

Representing: Los Angeles County.

Whereas, the Jenkins-Keogh philosophy of equal-
ity in taxation has been recognized as being fair and
equitable; and

Whereas, in spite of the fact that the members
of Congress have agreed that this is fair and in or-
der, they have persisted in postponing this legisla-
tion; and

Whereas, if an example could be set by enacting
legislation of this sort at the state level, it might
have a salutary influence in Congress; now, there-
fore, be it

Resolved : That this House of Delegates hereby
instruct its Council to implement this approach by
appropriate legislation endeavors at the state level so
that, at least as far as the state income tax is con-
cerned, the self-employed individual will be treated
comparably with the individual employed by a cor-
poration, namely, that he not pay taxes on funds
set aside for his retirement until he actually receives
these funds.

ACTION : Adopted by House.

ill

MEDICAL FEES UNDER THE CALIFORNIA
WORKMEN'S COMPENSATION LAWS

Resolution No. 7.

Author: E. Nelson Moore.

Representing: San Benito County Medical Society.

Whereas, there is an official minimum medical
fee schedule for services rendered under the Cali-
fornia Workmen’s Compensation Laws, as adopted
by the Industrial Accident Commission of the State
of California in 1954 and amended in 1957 and
1959; and

Whereas, this schedule does not reflect changes
in the practice of medicine and the development of
new procedures and phases of medical practice; and
Whereas, the 1960 Relative Value Studies as
adopted by the California Medical Association Coun-
cil does reflect these changes; now, therefore, be it

ACTION: Referred to Committee on Fees.

VOL. 97. NO. 2 • AUGUST 1962

PRIVATE PRACTICE DEFINITION

Resolution No. 8.

Author: Tenth District.

ACTION: Withdrawn by author.

1 1 i

DRIVER LICENSE REGULATIONS

Resolution No. 9.

Author: Tenth District.

Whereas, the incidence of injuries and deaths
from automobile accidents in California is steadily
rising; and

Whereas, the number of vehicles on California’s
highways is increasing; and

Whereas, the present procedures for driver
licensing are inadequate to the degree they do not
provide for adequate medical evaluation and screen-
ing of new and renewal driver license applicants;
now, therefore, be it

Resolved : That the California Medical Associa-
tion urge the enactment of legislation designed
to provide adequate medical evaluation for new and
renewal applicants for drivers’ licenses; and be it
further

Resolved : That the C.M.A. Commission on Com-
munity Health Services function in an advisory
capacity to the legislature during its considerations
of the nature and frequency of medical evaluation
required and of the medical conditions for which a
driver’s license should be restricted or denied.

ACTION: Referred to Committee on Traffic Safety.

i i i

STATEWIDE FLUORIDATION CAMPAIGN

Resolution No. 10.

Author: Tenth District.

Whereas, the scientific world has almost unani-
mously recognized the adjustment of the fluoride
level of water supplies to the optimum concentration
considered to best combat tooth decay to be a safe,
beneficial, practical, inexpensive health measure;
and

Whereas, isolated and sporadic community and
district efforts to implement this measure have, for
the most part, been thwarted by a state and nation-
wide organized effort, much to the detriment of the
dental and general health of the population ; and

Whereas, a sizable portion of the population of
this country will need to take this nutrient individ-
ually; and

Whereas, many organizations and individuals
stand ready to unite with medicine in a drive to im-
plement fluoridation measures; now, therefore, he it

Resolved: That the California Medical Associa-
tion initiate early action to create in cooperation

with all other interested groups such as the Califor-
nia Dental Association, an organization to promote
an all-out informative statewide fluoridation cam-
paign vigorously pursued in all media on state and
local levels with the objective of stimulating local
governments to press the proper fluoridation legis-
lation during a single period selected so that organ-
ized opposition will be unable to concentrate its
efforts as it has in sporadic and isolated instances;
and be it further

Resolved : That this campaign inform physicians
and dentists practicing in areas lacking community
water supplies of the benefits of prescribing this
nutrient for their individual patients.

ACTION: Referred to Council.

RELEASE OF PENSION PLAN FUNDS FOR
MEDICAL BENEFITS

Resolution No. 11.

Author: San Mateo delegation.

Whereas, those persons now receiving retirement
benefits from pension, profit sharing, or stock bonus
plans are prohibited by law from receiving payment
of benefits for sickness, accident, hospitalization and
medical expenses for themselves or members of
their families; and

Whereas, these various plans now have an ac-
cumulated value of approximately $40,000,000,000;
and

Whereas, the provision of such benefits to these
persons will make adequate medical services more
available to a significant and increasing proportion
of the nation’s retired, who have earned this privi-
lege; now, therefore, be it

Resolved: That the California Medical Associa-
tion, through its members, actively support HR
10117 which seeks to amend the Internal Revenue
Code to legalize the provisions of such benefits.

ACTION : Adopted by House.

iii

TAX DEDUCTIONS

Resolution No. 12.

Author: San Mateo delegation.

(Resolution No. 12 was considered together with
Resolution No. 31 and the following substitute reso-
lution was developed in the place of the original
resolutions.)

Resolved : That the California Medical Associa-
tion support state and federal legislation which will
eliminate the ceiling on the total allowable deduction
for medical expenses and which will also remove the
percentage limits of adjusted gross income allowed
for such expenses, making the entire amount de-

CALIFORNIA MEDICINE

ductible, including the whole of all health insurance
premiums; and he it further

Resolved : That the Council of the C.M.A. take
appropriate steps on a state and national level to
effect these resolutions.

ACTION: Adopted by House.

ill

COORDINATED MEDICAL CARE

Resolution No. 13.

Author: San Mateo delegation.

Whereas, Coordinated Medical Care of the pa-
tient in the home has been conclusively proven to
be beneficial to the patient, the family, the hospital,
and, therefore, the physician; and

Whereas, there are at the present time at least
eight coordinated Home-Care programs in the State
of California; and

Whereas, the California Physicians’ Service is
currently running a pilot program on financing
such a program ; now, therefore, be it

Resolved: That California physicians be urged
to assume the leadership in, as well as the support
of such community projects; and be it further

Resolved : That all voluntary health insurance
agencies, including California Physicians’ Service,
be urged to accept and subsidize all such programs
which are adecjuately projected and organized.

ACTION : Adopted by House.

INCREASING COST OF RUNNING THE C.M.A.

Resolution No. 14.

Author: San Mateo delegation.

ACTION : Not adopted by House.

111

NATIONAL BLUE SHIELD PLAN

Resolution No. 15.

Author: Ward L. Hart.

Representing: San Mateo County Medical Society.

ACTION : Not adopted by House.

iii

OUTLINE OF AN ADEQUATE MEDICAL PROGRAM

Resolution No. 16.

Author: William H. Thompson.

Representing: San Mateo County Medical Society.

Whereas, the medical profession is able to best
determine what constitutes good medical care and
thus an ideal medical program; and

Whereas, many medical programs as proposed
by and actually sold or contracted for or by insur-
ance companies, lay organizations, labor unions,
corporations, and local, state and federal agencies,

and government and individuals fall far below even
minimum needs; and

Whereas, frequently an inadequate medical pro-
gram may in actuality be expensive and even at
times detrimental; now, therefore, be it

Resolved: That the California Medical Associa-
tion make available publicly and as rapidly as pos-
sible the outline of an adequate medical program
which the above organizations and individuals
should expect and demand; and be it further

Resolved : Set up state and local committees who
would be available as consultants to further advise
groups and individuals along these lines; and be it
further

Resolved: That the California Medical Associa-
tion shall not ascribe or infer a cost of this program.

ACTION : Adopted by House.

BIRTH CONTROL IN CALIFORNIA

Resolution No. 17.

Author: William H. Thompson.

Representing - San Mateo County.

(Resolutions Nos. 17, 30 and 37 were considered
as a group. A substitute resolution for No. 17 was
presented and approved by the House; with amend-
ment, Nos. 30 and 37 were also adopted.)

Whereas, the need for family planning exists in
various socioeconomic groups of the population;
and

Whereas, such family planning services are not
available in many communities; and

Whereas, these services should properly be in-
cluded with every adequate medical care program;
now, therefore, be it

Resolved: That the California Medical As-
sociation go on record as stating that an adequate
medical program should include family planning
education and service.

ACTION: Adopted by House.

i i i

BASIC PRINCIPLES IN MEDICAL INSURANCE

Resolution No. 18.

Author: William H. Thompson.

Representing: San Mateo County Medical Society.

(Resolutions Nos. 18, 40, 53 and 54 were consid-
ered as a group. All were voted to be referred to an
ad hoc committee to be appointed by the Speaker
of the House of Delegates.)

WHEREAS, any medical insurance or care pro-
gram, either private or governmentally operated
must of necessity have certain defined limits of cost
and thus payments; and

VOL. 97, NO. 2 • AUGUST 1962

Whereas, there must be built-in controls, both
moral and legal, applied to recipients of service as
well as the purveyors and payers of this service;
now, therefore, be it

Resolved: That the California Medical Associa-
tion state publicly and strive for in all its delibera-
tions with any governmental medical care agency,
as well as other medical insurance plans the follow-
ing basic principles:

1. Payments must be made by the payer to the
recipient of the service according to a schedule
which pays a reasonable amount toward, but rarely
the total, usual reasonable customary fee,

2. Each recipient of service must have preserved
his right of freedom as to choice of physician,

3. It is the right of each recipient of service to
receive up to the scheduled amount toward his doc-
tor’s fee and hospital care and other medical costs,
whether the physician accepts this, in toto, or as
part payment,

4. The local medical societies must vigorously
protect the patient and physicians as to the justice
of the fees and services provided.

ACTION: Referred to ad hoc committee to be ap-
pointed by Speaker of House.

i i i

FORMATION OF PROFESSIONAL ASSOCIATIONS
IN CALIFORNIA

Resolution No. 19.

Author: William H. Thompson.

Representing: San Mateo County Medical Society.

Whereas, the present tax structure is inequitable
in not allowing physicians the same benefits on
retirement funds as is allowed the vast majority of
citizens employed by corporations; and

Whereas, certain other tax-free benefits such as
life, health and accident insurance are also denied
physicians, but are available to persons in industry;
and

Whereas, the partnership laws in the State of
California prohibit the formation of a professional
association, such as may be formed in certain other
states; and

Whereas, on December 5, 1957, the House of
Delegates of the American Medical Association has
affirmed the ethical propriety of the formation of
professional associations provided ownership and
management remains in the hands of the licensed
physicians; and

Whereas, the Council of the California Medical
Association has opposed legislation designed to cor-
rect this inequitable taxation of professional per-
sons; now, therefore, be it

Resolved: That this House of Delegates instruct
the Council of the California Medical Association to
actively initiate and support such legislation as is
necessary to allow the formation of professional as-
sociations in the State of California; and be it
further

Resolved: That the Council of the California
Medical Association report the results of its efforts
to the 1963 meeting of this House of Delegates.

ACTION: Referred to Council; see Resolution No. 1.

i 1 i

LIAISON COMMITTEES TO COUNTY GOVERNMENTS

Resolution No. 20.

Author: San Mateo delegation.

Whereas, a significant and ever increasing num-
ber of persons residing in California receive medical
services, both in-patient and out-patient, through
various governmental aid programs, administered
locally by county agencies; and

Whereas, such local administration is preferable
to one more centralized; and

Whereas, the physician is the keystone to the pro-
vision of all medical services; and

Whereas, these programs deserve the best pos-
sible implementation; now, therefore, be it

Resolved: That the California Medical Associa-
tion encourage its constituent societies to offer their
expert consultative services to the appropriate county
boards supervising such provisions of medical serv-
ices by means of permanent liaison committees.

ACTION : Adopted by House.

iii

FEE SCHEDULE OF THE M.A.A. PROGRAM IN
CALIFORNIA

Resolution No. 21.

Author: San Mateo delegation.

Whereas, the medical profession has supported
the Kerr-Mills principle of state and federal pay-
ment of locally administered comprehensive medical
care for the elderly of limited means; and

Whereas, the Medical Assistance for Aged
(M.A.A.) program’s fee schedule as administered
in California is based upon a subsidy from physi-
cians in the form of low payment often below cost;
and

Whereas, unqualified endorsement of this pro-
gram and its fees by the California Medical Associa-
tion forces practicing physicians to choose either
acceptance of inadequate fees or rejection of the
Kerr-Mills principle; and

Whereas, this present program and its fees may
be the prototype of similar programs in the future;
now, therefore, be it

CALIFORNIA MEDICINE

Resolved: That this House of Delegates:

1. Express its strong disapproval of the unreal-
istic fee schedule of the M.A.A. program in Cali-
fornia,

2. Support only those plans which provide quality
care for patients and realistic compensation for pro-
fessional service,

3. Urge adoption of a $5 unit conversion factor
for each of the four sections of the 1960 Relative
Value Studies for the current program year,

4. Provide for annual revision of this schedule
in accord with the changing economy and the most
recent Relative Value Studies.

ACTION: Referred to ad hoc committee, together
icitli Nos. 22 and 39; see Resolution No. 18.

i i 1

STATE MEDICAL CARE FEE ALLOWANCES

Resolution No. 22.

Author: San Mateo delegation.

Whereas, in the past, the leaders of the California
Medical Association have encouraged the members
to participate in the O.A.S. and M.A.A. programs
despite a professional fee inequitable for much of
the membership; and

Whereas, this is in effect an unintended subsidy
of government by the medical profession; and
Whereas, all parties concerned, government and
private, agree that this is unjust; now, therefore,
be it

Resolved : That the California Medical Associa-
tion inform the government of the State of Cali-
fornia that it will not recommend that its members
continue such participation, or enter into participa-
tion of any future program in which the fee is also
unjust.

ACTION: Referred to ad hoc committee; see Reso-
lution No. 18.

i i i

CHARITABLE CONTRIBUTION OF SERVICES

Resolution No. 23.

Author: William H. Thompson.

Representing: San Mateo County.

ACTION : Not adopted by House.

tit

DISPENSING OF DRUGS TO GOVERNMENT PATIENTS

Resolution No. 24.

Author: Harry F. Smith.

Representing: San Mateo County.

Whereas, many physicians dispense their own
medication to their private patients; and

Whereas, “direct dispensing” is not possible un-
der the O.A.S., A.N.C., and M.A.A. programs; and

Whereas, the advantages to direct dispensing
include:

1. Greater economy (e.g., often two or three
tablets) ,

2. Greater convenience to patient (often obviates
a trip to the pharmacist when such a trip is a hard-
ship),

3. Less duplication (often allows physician to
“try” a medication prior to prescribing a larger
quantity) ,

4. Greater speed in initiating therapy, and

Whereas, there are many precedents among

which is the Workmen’s Compensation Law; now,
therefore, be it

Resolved: That the House of Delegates of the
C.M.A. use every effort available to obtain re-
imbursement to individual physicians for drugs
dispensed under current and future government-
financed medical programs.

ACTION : Referred to Liaison Committee to State
Department of Social Welfare.

■tii

OVER-INSURANCE

Resolution No. 25.

Author: T. D. Englehorn.

Representing: Monterey County.

Whereas, many people have insurance coverage
for medical, surgical and hospital costs with more
than one insurance carrier, either individual and/or
group insurance through employment, and/or as a
dependent of their spouse through individual or
group insurance, and frequently at the same time
are covered by industrial insurance; and

Whereas, this has been recognized by the Insur-
ance Commission and State Legislature without any
appropriate solution to the problem; and

Whereas, this results in increasing materially
the costs of medical care at a time when efforts are
being made to prevent further inflation of such
costs; and

Whereas, this also frequently results in the indi-
vidual making more money while disabled than
when working, making for prolonged hospitalization
and slowing down of recovery; now, therefore,
be it

Resolved: That the California Medical Associa-
tion recognizes this as a problem and that it shall
recommend further study and appropriate action
by the Insurance Commissioner and the State Legis-
lature.

ACTION: Referred to Commission on Medical

Services.

VOL. 97, NO. 2 • AUGUST 1962

MEDICAL DISCIPLINARY BOARD

Resolution No. 26.

Author: Leon P. Fox.

Representing: Santa Clara County Medical Society.

Whereas, disciplinary procedure for violations
of medical practice regulations in California is mul-
tifaceted with many areas of confusion, lack of cov-
erage and questionable authority; and

Whereas, the State of Washington has by legis-
lative action established an effective board, consist-
ing of doctors of medicine elected by all licensed
physicians, which successfully controls all disci-
plinary matters related to the practice of medicine;
and

Whereas, this board includes the jurisdiction of
the medical society, board of medical examiners,
state board of health and other pertinent bodies;
and

Whereas, the California Medical Association is
constituted for the purpose of protecting the public
health and bettering the medical profession; now,
therefore, be it

Resolved: That this House of Delegates direct
the Committee on Legislation or other appropriate
committee to study the feasibility of instigating leg-
islation which would establish an overall authorita-
tive Medical Disciplinary Board in California; and
be it further

Resolved: That the Committee on Legislation be
further directed to promulgate such legislation if it
is found to be opportune.

ACTION: Referred to Council.

INSURANCE REQUIREMENTS

Resolution No. 27.

Author: Donald M. Gallagher.

Representing: San Francisco.

ACTION : Withdrawn by author.

111

CALIFORNIA PHYSICIANS' SERVICE

Resolution No. 28.

Author: L. Henry Garland.

Representing: San Francisco.

ACTION : Not adopted by House.

iii

REFERENCE COMMITTEE NO. 2

Resolution No. 29.

Author: San Francisco delegation.

Whereas, the responsibilities of C.M.A. Reference
Committee No. 2 are to serve as a committee of in-
quiry, to hold an open meeting at the time of the
state convention in order that delegates may ask
questions regarding the financial affairs of the

association, to review the budget for the next year,
to make a recommendation setting the dues for the
ensuing year, to review the reports of the secretary
and the executive secretary, and to make a recom-
mendation concerning these reports to the House of
Delegates for their approval, and to perform such
other duties as may be directed to them; and

Whereas, the members of the committee bring
no special knowledge to the state convention con-
cerning the financial affairs of the association; and

Whereas, the proper functioning of this commit-
tee would appear to be both necessary and desirable;
and

Whereas, the Association has become big busi-
ness, spending $1,300,000 a year; now, therefore,
be it

Resolved: That the following recommendations
be approved and implemented:

1. The committee shall be considered semi-per-
manent. It shall study, throughout the year, the ex-
penditure of the Association’s funds, and report to
the House of Delegates at the annual session,

2. To accomplish the above, the committee shall
have access to the books of the California Medical
Association and its fully owned affiliates; it shall
obtain consultation with the C.M.A. auditor as it
may deem necessary; it shall meet during the year
as it shall find necessary; and it may occasionally
request members of the Association and employees
of the Association to meet with it,

3. The new member or members should be ap-
pointed at least 60 days before the convention.

ACTION: Referred to Speaker and Council.

iii

ABORTION AND STERILIZATION PROCEDURES

Resolution No. 30.

Author: San Francisco delegation.

Whereas, the current law in California pertaining
to therapeutic abortions and sterilizations is not
adequate to serve the health and welfare needs of
the people; and

Whereas, a proposed revision of the law is under
study by the Legislature and would allow the con-
sideration of therapeutic abortion and sterilization
procedures to protect the health of a mother, where
now the only consideration is that her life be threat-
ened; now, therefore, be it

Resolved : That the C.M.A. go on record as sup-
porting legislation protecting the health of a mother
in the consideration of therapeutic abortion and
sterilization procedures; and be it further

Resolved: That the facilities of the C.M.A. be
used to provide any pertinent information for the
use of the legislators.

ACTION: Adopted by House ; see also No. 17.

CALIFORNIA MEDICINE

INSURANCE PREMIUMS TAX DEDUCTION

Resolution No. 31 : See Resolution No. 12.

Author: San Francisco delegation.

FOREIGN MEDICAL SCHOOL GRADUATES

Resolution No. 32.

Author: San Francisco delegation.

Whereas, at present the restrictive laws on post-
graduate training for foreign medical school gradu-
ates present many difficulties; now, therefore, be it

Resolved : That the House of Delegates recom-
mend modification of the Medical Practice Act to
accomplish the following:

1. That qualified physicians from other countries
be permitted to undergo residency training in Cali-
fornia for periods up to five years providing the
candidate (a I satisfactorily completes the ECFMG
examination; (b) meets the requirements of and is
accepted for an approved residency; (c) register
with the Board of Medical Examiners,

2. No time spent in such training to be credited
toward qualifying for medical licensure in Califor-
nia. Physicians trained under this program who de-
sire to qualify will be required to fulfill all the
requirements pertaining to nonaliens,

3. Phvsicians entering California under this pro-
gram will not be eligible to start a program for
licensure until after having returned to their own
country for a period equal in time to that spent in
training here.

ACTION: Referred to Council.

EMERGENCY RESOLUTION EVALUATION

Resolution No. 33.

Author: Tenth District.

Whereas, many resolutions are completed and
introduced only the week prior to the annual C.M.A.
House of Delegates meeting makes their circulation,
evaluation, and assignment difficult and therefore,
at times, disappointing to interested members, dele-
gates, or delegations; and

Whereas, it has heretofore been considered the
responsibility of the Council or Speaker of the
House of Delegates to receive and determine the
assignment of such resolution; now, therefore, be it

Resolved :

1. That an emergency resolution evaluation com-
mittee be created to receive and consider all resolu-
tions introduced after an announced date, generally
seven days prior to the opening meeting of the
House of Delegates,

2. That such committee be composed of chairmen
of the House Reference Committee with the chair-
man of Reference Committee No. 1 serving as chair-
man of the emergency resolution evaluation commit-
tee (Reference Committee chairmen are appointed
well in advance of the House of Delegates meeting),

3. That this committee be assigned all resolutions
considered in such “late” or “emergency” category
and empowered to reject or assign such resolutions
as the merits of the resolution dictate in the com-
mittee’s estimation,

4. That the intent and purpose of this resolution
will not and does not preclude a delegate or dele-
gation from introducing emergency resolutions un-
der the call for new business with the attendant
rules as has heretofore been the custom.

ACTION: Adopted through adoption of By-Law
Amendment No. 7.

i i i

SPECIALTY PRACTICES AS PROFESSIONAL SERVICES

Resolution No. 34.

Author: Tenth District.

Whereas, the California Medical Association and
the American Medical Association recognize the
specialties of Anesthesiology, Medicine, Neurology,
Pathology, Radiology, etc., as the practice of medi-
cine; and

Whereas, the C.M.A. and A.M.A. insist that their
members in the above specialties conduct their pro-
fessional practice in the same ethical manner as
members in other fields of medicine as concerns
physician-patient-hospital relationships; and

Whereas, the C.M.A. and A.M.A. therefore in-
sist that these said physicians be accorded the same
considerations as all other physicians by “third
parties”; now, therefore, be it

Resolved: That the California Medical Associa-
tion vigorously disapprove the inclusion, as a Hos-
pital Service or a Professional Hospital Service, of
Anesthesiology, Medicine, Neurology, Pathology,
Radiology, etc., in all “Guiding Principles,” in gov-
ernmental directives and/or schedules referring to
hospital services, in commercial health and accident
insurance contracts and schedules, etc.; and be it
further

Resolved: That the C.M.A. specifically requests
the removal of paragraph VI “Professional Serv-
ices,” under the general heading of “Standard Hos-
pital Services,” in the publication entitled “Guiding
Principles for Hospitals” published by the San
Francisco Hospital Conference and the Hospital
Council of Southern California; and be it further

Resolved: That this resolution be sent to the
offices of each specialty society, to all health and
accident insurance carriers licensed in California,
to all hospitals in California and the California Hos-
pital Association, to the California Department of
Social Welfare and the Department of Public Health,
and to the United States Department of Health, Edu-
cation and Welfare.

ACTION: Adopted by House.

VOL. 97, NO. 2 • AUGUST 1962

LIBERTY AMENDMENT

Resolution No. 35.

Author: Leon P. Fox.

Representing: Santa Clara County Medical Society.

ACTION: Tabled by House.

NURSE PRACTICE ACT

Resolution No. 36.

Author: Santa Clara delegation.

Whereas, the California Legislature in 1957
amended the Nurse Practice Act to permit the estab-
lishment for a trial period of 5 years of two-year
courses of training leading Registered Nurse Licen-
sure; and

Whereas, courses under the legislation have been
established in 20 California junior colleges with 5
more due to open in the fall of 1962; and

Whereas, 11 of these junior college programs are
in communities which do not now have any nursing
school, and

Whereas, a study of these graduates in 1960 has
shown that their scores in the State Nursing Licen-
sure examinations were equal to the scores of grad-
uates of the standard, three-year nurse training
courses; and

Whereas, studies of employment of graduates of
these programs showed 71 per cent employed at the
end of one year after their graduation; and

Whereas, 75 per cent of the graduates are em-
ployed in the community where they were educated;
and

Whereas, the increase in population in California
with its concomitant increase in the number of phy-
sicians and of hospitals makes ever increasing num-
bers of well -trained registered nurses essential; and
Whereas, the present supply of registered nurses
is inadequate; and

Whereas, the trial period of 5 years for this two-
year program expires in 1962; now, therefore, be it
Resolved : That this House of Delegates of the
California Medical Association instruct the Council
of C.M.A. to instruct its Committee on Public Policy
to exert every effort to assure that the Nurse Prac-
tice Act be suitably amended in the 1963 Legislature
to authorize permanent inclusion of two-year pro-
grams leading to Registered Nurse Licensure.

ACTION: Referred to Council, with request for
prompt action.

ill

THERAPEUTIC ABORTION

Resolution No. 37.

Author: Santa Clara delegation.

Whereas, the existing laws relating to therapeu-
tic abortion and the present standards of practice

of reputable members of the medical profession in
acceptable hospitals in California are incongruous;
and

Whereas, Assembly Bill 2614, which is now
under study in the Criminal Procedures Committee
of the state legislature, does afford a practical and
scientific means of controlling justifiable abortion
by the use of authorized hospital committees; and
Whereas, the legal jeopardy of all licensed physi-
cians will be lessened by activating this law; now,
therefore, be it

Resolved: That this House of Delegates direct
the Committee on Legislation and other pertinent
bodies to strongly support the objectives of A.B.
2614 and use every effort to bring forth positive
action thereon.

ACTION: Adopted by House; see also No. 17.

i i i

BLOOD ALCOHOL TESTS

Resolution No. 38.

Author: E. Kash Rose.

Representing: Napa County Medical Society.

Whereas, the automobile accident rate and
deaths are constantly increasing in California and
a most common cause is driving while intoxicated;
and

Whereas, physicians so frequently become in-
volved in the determination of degree of intoxica-
tion; and

Whereas, at present there is considerable risk
legally to the physician who draws blood for alcohol
determination with or without consent; and

Whereas, it has been the policy of the C.M.A. to
be concerned with all facets of public welfare as
related to automobile injuries; now, therefore, be it
Resolved: That the C.M.A. sponsor or cause to
be sponsored in the California State Legislature
legal proper legislation to remove or lessen the risk
to physicians who desire to cooperate in drawing
of blood alcohol.

ACTION : Adopted by House.

i i i

STATE AGENCY FEE SCHEDULES

Resolution No. 39.

Author: Chairman of the delegation.

Representing: Alameda-Contra Costa Medical Association.

Whereas, fees paid by State agencies for medical
services under the Public Assistance Medical Care
Act are based on schedules adopted five or more
years ago ; and

Whereas, at that time the fees paid by these

CALIFORNIA MEDICINE

agencies were below the usual and customary
charges for the services rendered; and

Whereas, in the past five years there have been
increases in the physician’s overhead, in cost of
living, in wage scales, and in the salaries of person-
nel employed by the state to administer this pro-
gram; and

Whereas, there has been no increase in the fees
paid to doctors for medical services; and

Whereas, this has resulted in a restricted choice
of physicians for patients whose health services are
purchased under this program; now, therefore, be it

Resolved: That the California Medical Associa-
tion further urge the State of California to establish
realistic fees for medical services purchased by state
agencies, in keeping with the general medical costs
in each community, and thus provide for medical
care by physicians under all conditions of medical
practice.

ACTION : Referred to ad hoc committee ; see Reso-
lution No. 18.

i i i

USE OF STATE AGENCY FEES AS INDEMNITY
PAYMENTS

Resolution No. 40.

Author: Chairman of the delegation.

Representing: Alameda-Contra Costa Medical Association.

Whereas, state agency fee schedules provide lev-
els of payment substantially below the usual and
customary charges for physicians’ services; and

Whereas, many physicians are unable to provide
services to patients for these amounts; and

Whereas, this results in a limited choice of phy-
sicians; and

Whereas, patients are presently prohibited from
using these payments in a manner which will assist
them to whatever extent is necessary and appropri-
ate, thereby increasing the flexibility and produc-
tiveness of the program for the recipient; now,
therefore, be it

Resolved: That when the amounts provided by
state medical programs are less than the usual and
customary charges for the services provided, the
patient should have the right to use these substand-
ard fee allowances as partial indemnities toward his
physician’s normal charges, by prior agreement be-
tween the patient and his physician on the total fee
to be charged, and that the C.M.A. inform the Wel-
fare Department of the desirability of such a change
in the administrative rules governing state medical
programs.

ACTION: Referred to ad hoc committee ; see Reso-
lution No. 18.

MEDICAL REPORTS FOR GOVERNMENT AGENCIES

Resolution No. 41.

Author: Chairman of the Delegation.

Representing: Alameda-Contra Costa Medical Association.

Whereas, medical reports are frequently re-
quested from attending physicians by government
agencies; and

Whereas, many of these reports call for more
information than that customarily furnished as part
of the physician’s normal service to his patients;
and

Whereas, the preparation of such reports re-
quires the expenditure of professional and secre-
tarial time; and

Whereas, the value of the service is recognized
and paid by nongovernment insurance companies;
and

Whereas, government agencies do not provide
payment for such reports, and this fact increases the
number of reports required; now, therefore, be it
Resolved: That the California Medical Associa-
tion urge government agencies to provide remunera-
tion for medical reports requesting more information
than that which is customarily furnished as part of
the physician’s normal service to his patient, when-
ever it is not appropriate or feasible for the patient
to be charged for this service.

ACTION: Referred to Commission on Medical

Services.

NATIONAL BLUE SHIELD HEALTH INSURANCE PLANS

Resolution No. 42.

Author: Chairman of the delegation.

Representing: Alameda-Contra Costa Medical Association.

Whereas, inadequate health insurance benefits
lead to justifiable dissatisfaction on the part of the
public; and

Whereas, any deficiencies in Blue Shield plans
reflect unfavorably on the medical profession, since
this type of insurance is sponsored by organized
medicine; and

Whereas, greater progress has been made toward
comprehensive benefits and realistic coverage by the
Blue Shield plan in California (C.P.S.) than has
been made in many other states; and

Whereas, these advances would be nullified if
C.P.S. adopted any national Blue Shield plans of-
fering lesser benefits than those now provided by
C.P.S.; now, therefore, be it

Resolved: That national Blue Shield contracts
implemented in California should offer a range of
health services and payments at least equal to con-
tracts being currently offered by C.P.S.

ACTION : Adopted by House.

VOL. 97. NO. 2 • AUGUST 1962

CLAIMS REVIEWS

Resolution No. 43.

Author: Chairman of the delegation.

Representing: Alameda-Contra Costa Medical Association.

Whereas, government medical care programs re-
quire controls in the disbursement of funds for the
purchase of health services; and

Whereas, county medical societies have estab-
lished effective mechanisms to review medical prob-
lems, the propriety or necessity of medical services
rendered, and the level of fees charged by physi-
cians; and

Whereas, these problems are not always well-
understood by nonmedical personnel ; and

Whereas, unjustified rejections of claims for
medical services by government administrative per-
sonnel leads to reduced cooperation with govern-
ment medical programs by physicians; and

Whereas, the Public Assistance Medical Care
Plan under the Social Welfare Departments of the
counties has demonstrated the excellent and success-
ful use of these mechanisms in the form of medical
society committees; now, therefore, be it

Resolved : That government medical programs
should rely on the established mechanisms of local
county medical societies, rather than taking inde-
pendent and arbitrary action, in any cases where
there are questions of the proper medical practice,
or the proper charges for services, by physicians.
ACTION: Adopted by House.

i i i

CREATION OF NEW SURGICAL SUB-SPECIALTY

Resolution No. 44.

Author: Alameda-Contra Costa Medical Association.

Resolved : That the action taken by the Section
on General Surgery of the American Medical Asso-
ciation in sponsoring the proposed American Board
of Abdominal Surgery to the Advisory Board for
Medical Specialties does not reflect a widespread
considered judgment of American medicine and
should therefore be dismissed; and be it further
Resolved : That the California Medical Associa-
tion is uniformly opposed to the creation of a Board
of Abdominal Surgery on the basis of the fact that
it is redundant and will not supplement or reinforce
any phase of American medicine not already sur-
veyed by a specialty board; and be it further
Resolved: That the representatives of the State
of California to the American Medical Association
House of Delegates be requested to act in general
to promote the adoption of a similar resolution by
the American Medical Association House of Dele-
gates.

ACTION: Adopted by House in amended form
above.

TAX DEFERRED PENSION PLAN

Resolution No. 45.

Author: Chairman of the delegation.

Representing: Alameda-Contra Costa Medical Association.

Resolved: That the California Medical Associa-
tion House of Delegates use all influence to cause to
be introduced in the next session of California
Legislature a bill that permits tax-deferred use of
professional income for purposes of establishing
pension funds; and be it further

Resolved : That the California Medical Associa-
tion cooperate actively with other professional and
self-employed persons to endorse the passage of the
legislation.

ACTION : Referred to Council; see Resolution No. 1.

iii

PROFESSIONAL SELF-EVALUATION

Resolution No. 46.

Author: Samuel R. Sherman.

Representing: The Council.

Whereas, the ethical principles of most profes-
sions such as medicine, dentistry, law and others
require that the members continually strive to im-
prove the knowledge and skill of the profession and
make available to the public and their colleagues the
benefits of their professional attainments; and

Whereas, the members of such professions must
enforce and abide by self-imposed disciplines in
matters relating to the proper and ethical practice
of the profession; and

Whereas, the implementation of these principles
is required of physicians in the by-laws of hospitals
or statutes through professional evaluation and re-
view committees such as hospital medical audit, tis-
sue and record committees; and

Whereas, the work of these committees does not
specifically relate to the care given a particular
patient but rather pertains to maintaining and im-
proving the quality of professional care of all pa-
tients and of the continuing training for physicians;
now. therefore, be it

Resolved: That the House of Delegates of the
California Medical Association recommend to the
California State Legislature that a statute with the
following purpose be enacted — that the term writing
and record as used in laws relating to evidence
admissible in trial of action, shall not include re-
ports of medical audits, tissue committee or other
written self-evaluation conducted in hospitals by
the professional services, in compliance with rec-
ommendations of the Joint Commission on Accredi-
tation of Hospitals, or other such agencies for main-
taining or improving quality of professional care
for all patients and continuing training for phy-
sicians.

ACTION : Adopted by House.

CALIFORNIA MEDICINE

HEALTH INSURANCE EDUCATION

C.P.S. COMMENDATION

Resolution No. 47.

Author: Marin Medical Society.

Whereas, the California Medical Association, as
well as the American Medical Association, has ac-
tively supported the Health Insurance Industry in
promoting the utilization of voluntary health insur-
ance as the realistic approach to the financing of
medical care; and

Whereas, there exists an extremely broad diver-
gence in the types and quality of health and accident
insurance policies available to the citizens of Cali-
fornia; and

Whereas, insurance plans which offer unrealistic
benefits frequently cause disillusionment on the part
of the patient and create unexpected financial bur-
dens; and

WHEREAS, this serves to disrupt the relationship
between doctor and patient, and thereby limits the
physician’s ability to render optimum care; and

Whereas, the medical profession is most acutely
aware of the deficiencies of many health insurance
contracts currently being offered; now, therefore,
be it

Resolved: That the Council of the C.M.A. ini-
tiate a program to inform and educate the public
as to what contract benefits and desirable features
should be provided in a realistic health insurance
contract.

ACTION : Adopted by House.

111

NEW A.M.A. OFFICER

Resolution No. 48.

Author: Marin Medical Society.

Whereas, the problems involving the financing
of medical care in the United States have risen to
staggering proportions; and

Whereas, the vast majority of these problems are
nationwide in scope; and

Whereas, the American Medical Association is
the medical profession’s major provider of infor-
mation and advice to the public on the financing of
medical care; now, therefore, be it

Resolved: That the California Delegation to the
House of Delegates of the American Medical Asso-
ciation strongly consider suggesting the creation of
a second and separate position of Executive Vice-
President, which person’s sole duty will be to co-
ordinate all activities of the American Medical
Association in connection with the financing of
medical care.

ACTION : Adopted by House.

Resolution No. 49.

Author: Marin Medical Society.

Resolved: That the California Physicians’ Serv-
ice be commended for its efforts in exploring and
providing insurance programs for the indigent and
near-indigent in cooperation with local, state and
federal governmental agencies; and be it further

Resolved: That the California Physicians’ Serv-
ice be instructed by this House to continue in these
efforts and to utilize existing medical care legisla-
tion to the fullest extent possible.

ACTION : Adopted by House.

RATTIGAN ACT

Resolution No. 50.

Author: Marin Medical Society.

Whereas, the Rattigan Act is proving to be an
effective means of assisting in the long term medical
care of California’s indigent aged population; and

Whereas, it has been the policy of the California
Medical Association to give articulate support to
this act. and to explore ways and means of still fur-
ther improving it; and

Whereas, the current 30-day waiting period has
caused certain inequities to occur in terms of total
costs which must be borne by the patient depending
on the particular medical problem involved; now,
therefore, be it

Resolved: That the Council of the California
Medical Association or its representatives, meet with
the State Department of Social Welfare, to consider
the feasibility of amending the Rattigan Act to allow
for a fixed dollar expenditure and/or a reduced
waiting period before coverage begins, rather than
the 30-day waiting period which is currently in
force.

ACTION : Adopted by House.

iii

COUNTY SOCIETY APPROVAL FOR
C.P.S. ACTIVITIES

Resolution No. 51.

Author: Robert Stragnell.

Representing: Los Angeles County.

Whereas, some of the policies of California Phy-
sicians’ Service do not necessarily conform to the
expressed desires of some county medical societies;
and

Whereas, criticism has been directed toward
California Physicians’ Service for failure to notify
certain counties of pending contractual negotia-
tions; now, therefore, be it

Resolved: That where major contracts are being
negotiated by C.P.S., consultation be made with the

VOL. 97, NO. 2 • AUGUST 1962

appropriate governing body of the county medical
society.

ACTION: Adopted by House in above amended
form.

i i i

CALIFORNIA PHYSICIANS' SERVICE— ITS PURPOSE

Resolution No. 52.

Author: L.A.C.M.A. delegation.

ACTION: Not adopted by House.

ADOPTION OF THE PRINCIPLE OF INDIVIDUAL
RESPONSIBILITY

Resolution No. 53.

Author: L.A.C.M.A. delegation.

Whereas, the practice of medicine is currently
under pressure by some legislators to convert it
piecemeal into a government controlled system ; and

Whereas, a government controlled system lacks
the element of individual responsibility; and

Whereas, government bureaucracy breeds me-
diocrity; and

Whereas, it is the responsibility of American
medicine to maintain the pattern of excellence and
reject government domination and bureaucratic
control; and

Whereas, the medical profession needs a work-
able mechanism by which it can unite its members
to permanently reverse the inroads of government
domination and preserve the free enterprise system;
now, therefore, be it

Resolved : That the California Medical Associa-
tion reject past and future programs that encourage
bureaucratic control of medicine and immediately
approve and adopt those systems which embody the
principle of individual responsibility.

ACTION: Referred to ad hoc committee ; see Reso-
lution No. 18.

i 1 i

APPLICATION OF INDIVIDUAL RESPONSIBILITY
TO STATE AND FEDERAL PROGRAMS

Resolution No. 54.

Author: L.A.C.M.A. delegation.

Whereas, the present California State Welfare
Program (O.A.S. et al. ) is operated under the prin-
ciple of collective responsibility and has essentially
rejected placing responsibility on relatives (Section
2181, as amended, Welfare and Institutions Code) * ;
and

Whereas, under the present welfare program, the
recipient has no responsibility and his relatives have
practically no legal responsibility (Section 2181, as
amended, effective January 1, 1962) ; and

•Legal responsibility of a child for parent, i.e., male, married,
two children, income under $1,000.00 per month. Legal financial
responsibility $0.00.

Whereas, California Medical Association’s con-
tinued participation in a bureaucratically controlled
program of the vendor-type, only provides the basis
for future passage of similar programs; now, there-
fore, be it

Resolved: That the California Medical Associa-
tion recommend to the State Welfare Board, through
our Advisory Committee, that the entire California
State Welfare Program be returned immediately to
the recipient system embodying individual respon-
sibility.

ACTION: Referred to ad hoc committee ; see Reso-
lution No. 18.

AID TO NEEDY CHILDREN

Resolution No. 55.

Author: L.A.C.M.A. delegation.

Whereas, the Department of Social Welfare has
radically restricted the medical procedures which
can be used on recipients of medical care under the
Aid to Needy Children Program; and

Whereas, such restricted medical care is sub-
standard and constitutes a hazard to the health and
lives of recipients of care under this program, there-
fore, be it

Resolved : That the California Medical Associa-
tion objects to the curtailment of medical pro-
cedures by the Department of Social Welfare; and
be it further

Resolved : That when funds are not available to
provide an adequate quality of medical care, the
California Medical Association strongly urges the
Department of Social Welfare to transfer some of
the involved recipients to other medical facilities,
such as county hospitals.

ACTION : Adopted by House.

1 1 1

ACCEPTANCE OF REGIONAL STANDARD FORMS
BY STATE WELFARE AGENCIES

Resolution No. 56.

Author: L.A.C.M.A. delegation.

Whereas, the current California State Welfare
Program employs a vast system providing medical
care to the needy; and

Whereas, completion of state forms and prescrip-
tion blanks increase the physicians’ overhead costs;
and

Whereas, physicians are desirous of furnishing
care at the most equitable possible cost; and

Whereas, such private agencies as Blue Cross,
under similar circumstances, are able to process
standard forms; now, therefore, be it

Resolved: That California Medical Association
reappraise its policy of using State Welfare forms

100

CALIFORNIA MEDICINE

and advise the State Welfare Board that it accept
standard forms as used in the various counties.
ACTION : Adopted by House.

i i i

PROTECTION OF PHYSICIANS FROM STATE
CONTROL

Resolution No. 57.

Author: L.A.C.M.A. delegation.

Whereas, cooperation with any state and federal
programs operating under the vendor concept en-
tails direct payment of physicians by government
agencies; and

Whereas, acceptance of financial remuneration
from the government constitutes de facto employ-
ment and control of physicians by these agencies
and bureaus; and

Whereas, the practicing American physician has
no desire whatsoever in becoming a government
employee (hireling) ; and

Whereas, American Medicine can only continue
to be free under a system which embodies and
practices individual responsibility; now, therefore,
be it

Resolved: That the California Medical Associa-
tion immediately press for abolition of the vendor
concept in favor of the recipient concept in all pub-
lic medical programs in California.

ACTION: Referred to ad hoc committee; see Reso-
lution No. 18.

iii

GUIDING PRINCIPLES FOR PHYSICIAN-HOSPITAL
RELATIONSHIPS

Resolution No. 58.

Author: L.A.C.M.A. delegation.

ACTION : Not adopted by House.

DELETION OF PAR. VI FROM "GUIDING
PRINCIPLES FOR HOSPITALS"

Resolution No. 59.

Author: L.A.C.M.A. delegation.

Whereas, the California Hospital Association is
distributing a brochure entitled “Guiding Principles
for Hospitals”; and

Whereas, Paragraph VI of the “Guide” states
the following: Professional Services — X-ray, Physi-
cal Medicine, Laboratory, Electroencephalography,
Electrocardiography, etc., are professional depart-
ments, and fees charged should be based upon the
usual and customary charges in this area. The
California Medical Association and the California
Hospital Association have approved the recommen-
dation that the fee be assigned by the medical spe-
cialist to the hospital for collection ; and

Whereas, the American Medical Association has
defined Roentgenology, Neurology, Pathology, etc.,
as the practice of medicine and defined the profes-
sional services of physicians in these specialties as
medical services; and

Whereas, Principles and directives concerning
the professional services of physicians in hospitals
are under the jurisdiction of the physician and the
hospital medical staff, not the hospital administra-
tion or hospital association; now, therefore, be it

Resolved: That the California Medical Associa-
tion rescind their recommendation that X-ray, Physi-
cal Medicine, Laboratory, Electroencephalography,
Electrocardiology, etc., fees be assigned by the
medical specialist to the hospital for collection; and
be it further

Resolved: That the California Medical Associa-
tion request the California Hospital Association to
delete Paragraph VI and all reference of profes-
sional services provided by medical specialists from
their brochure of “Guiding Principles for Hos-
pitals.”

ACTION : Adopted by House.

iii

NONPROFIT PROFESSIONAL LIBRARIES

Resolution No. 60.

Author: L.A.C.M.A. delegation.

Whereas, “Free Public Libraries” and property
used for hospital and scientific purposes are exempt
from taxation under the Law of California; and

Whereas, medical libraries are now being taxed
although they are devoted to scientific purposes and
to the spread of medical knowledge, for the benefit
of the community as a whole; now, therefore, be it

Resolved: That the Legislative Committee be
instructed to have introduced into the Legislature a
law granting exemption from taxation to nonprofit
professional libraries open to all members of the
respective professions.

ACTION: Referred to Council, ivith instructions
that “ all practical steps be taken to implement reso-
lution.”

iii

LEGISLATION RE CORONER S OFFICE

Resolution No. 61.

Author: L.A.C.M.A. delegation.

Whereas, the State Bar Association has ap-
pointed a committee to recommend changes in the
law regulating the Coroner’s Office; and

Whereas, there is a need for improving the med-
ical and scientific standards in many coroners’ of-
fices; now, therefore, be it

Resolved: That the Council of the California
Medical Association appoint a special committee of

VOL. 97, NO. 2 • AUGUST 1962

101

men familiar with the activities of the Coroner to
meet with the committee of the State Bar Association
for the purpose of developing legislation which can
be supported by the Bar and the California Medical
Association.

ACTION : Adopted by House.

i 1 i

SELF-EMPLOYED RETIREMENT ACT— STATE OF
CALIFORNIA

Resolution No. 62.

Author: L.A.C.M.A. delegation.

Whereas, the Jenkins-Keogh principle of equality
in taxation has been recognized as being fair and
equitable; and

Whereas, in spite of the fact that the members
of Congress have agreed that this is fair and just,
yet certain members have persisted in postponing
this legislation ; and

Whereas, an example can be set by enacting leg-
islation at the state level, which would have a salu-
tary influence on Congress ; now, therefore, be it

Resolved: That this House of Delegates instruct
its Council to implement this principle by urging
appropriate legislative measures at the state level,
so that as far as the California state income tax is
concerned, the self-employed individual will re-
ceive the same treatment taxwise as afforded indi-
viduals employed by corporations, namely, that he
defer payment of taxes on funds set aside for his
retirement until he actually receives said funds.

ACTION: Referred to Council; see Resolution No. 1.

iii

DIRECT ELECTION OF C.M.A. COUNCILORS

Resolution No. 63.

Author: L.A.C.M.A. delegation.

Whereas, the California Medical Association
councilors are now elected by the California Medical
Association House of Delegates; and

Whereas, a substantial number of the current
delegates are in favor of direct election of California
Medical Association councilors by the membership
at large; and

Whereas, the general membership earnestly de-
sires the right to vote for their California Medical
Association councilors; and

Whereas, the direct election by the membership
at large will be following American custom of equal
franchise; and

Whereas, the adoption of this method of voting
for California Medical Association councilor officers
will give the membership a more direct responsi-
bility in the affairs of California Medical Associa-
tion; now, therefore, be it

Resolved: That the House of Delegates of the
California Medical Association direct the Council
of the California Medical Association to initiate the
necessary steps to initiate the change in the By-Laws
and/or Charter structure of California Medical As-
sociation, to provide that the councilors of Califor-
nia Medical Association will be elected by direct
vote of the general active membership within each
councilor district of California Medical Association,
by July 1, 1964.

ACTION: Referred to special ad hoc committee, to-
gether with 1962 Constitutional Amendment No. 4
and 1962 By-Law Amendment No. 12 and Resolution
No. 81.

iii

QUALITY OF MEDICAL CARE

Resolution No. 64.

Author: L.A.C.M.A. delegation.

Whereas, the citizens of the State of California
expect the medical profession to provide the best
quality medical care for all persons regardless of
ability to pay; and

Whereas, the medical profession has no legal
control over the quality of medical care dispensed;
and

Whereas, a small but significant number of peo-
ple require assistance in the financing of their medi-
cal care; and

Whereas, the insurance principle has been found
to be a practical solution for said financing; now,
therefore, be it

Resolved: That the California Medical Associa-
tion request the Legislature of the State of California
to appoint a committee to meet in liaison with the
Council of the California Medical Association to
propose legislation to (1) provide legal means
whereby the medical profession can control the
quality of medical care dispensed in this State, and
(2) to indemnify financially needy citizens in the
purchase of health insurance.

ACTION : Referred to Council.

iii

APPOINTMENT OF CHAIRMEN OF C.M.A.

COMMISSIONS

Resolution No. 65.

Author: L.A.C.M.A. delegation.

ACTION : Not adopted by House.

iii

OPPOSITION TO SOCIALIZATION OF MEDICINE

Resolution No. 66.

Author: L.A.C.M.A. delegation.

Whereas, the physicians of the California Medi-
cal Association, guided by professional ethics and
maintaining high professional standards in prac-

102

CALIFORNIA MEDICINE

ticing under the American free enterprise system,
are now providing good medical care for all citi-
zens; and

Whereas, the King-Anderson Bill, or any similar
type of legislation, seeks to place medical care for
the aged, regardless of need, under Social Security
taxation, which would injure the patient-physician
relationship and would provide medical care regard-
less of need; and

Whereas, the King-Anderson Bill, or similar
federal legislation financed by Social Security taxa-
tion would impose unwarranted increases in pay-
roll taxes and would promote inevitable inefficiency
and other defects inherent in the administration of
welfare programs by the federal government; and

Whereas, legislation of the King-Anderson type
would result in medical practice of inferior quality
and yet more costly than that available through vol-
untary systems; now, therefore, be it

Resolved : That the members of the California
Medical Association continue their vigorous oppo-
sition to legislation of the King-Anderson type.

ACTION: Adopted by House in above form.

i i i

C.M.A. ACCELERATED PUBLIC RELATIONS PROGRAM

Resolution No. 67.

Author: Douglas Donath.

Representing: Los Angeles County.

ACTION : Not adopted by House.

i i i

THE PHYSICIAN IN PUBLIC RELATIONS

Resolution No. 68.

Author: Ian Macdonald.

Representing: Los Angeles County.

Whereas, a general conviction associates the
most favorable influence on the public image of
medicine with the patient-physician relationship;
and

Whereas, the physician usually is admired in the
singular, but held in low esteem as part of the or-
ganized whole; and

Whereas, a majority of physicians exhibit a
notable apathy in the face of the imminent engulf-
ment by the socialist juggernaut of state welfarism,
of the most effective system of medical care yet to
be devised by man; now, therefore, be it

Resolved : That the chief direction of an acceler-
ated public relations program be directed toward
making every physician an active focus of public
relations influence, in which effort the personnel in
public relations available to California Medical As-
sociation should devote their major time, energy and
talents.

ACTION : Adopted by House.

COORDINATED HOME CARE

Resolution No. 69.

Author: James C. Doyle.

Representing: Los Angeles County.

Whereas, the American people are entitled to
the best medical care available; and

Whereas, home care provides for coordination
of medical and ancillary services at a cost that is
considerably under that of the hospital; and

Whereas, patients are happier, recover quickly
at home, and a patient cared for at home frees a
hospital bed for one acutely or critically ill; and
Whereas, widespread acceptance of this program
could help in halting the spiralling cost upward of
accident and health insurance; and would make it
unnecessary to increase hospital facilities; and
Whereas, it should be stressed that coordinated
home care is a supplement, not a substitute, for ex-
isting medical care; and

Whereas, it is essential that all segments of so-
ciety be covered, the young, middle aged, as well as
the aged; the financially independent as well as the
less affluent and needy; and the care should include
acute, convalescent, rehabilitative, as well as the
chronic case; now, therefore, be it

Resolved: That the California Medical Associa-
tion alert and inform the physicians and county so-
cieties regarding the importance of this program,
and the need of early activation; and be it further
Resolved: That the California Medical Associa-
tion actively participate and collaborate with the
California Hospital Association, and other profes-
sions, to expedite the expansion of care in the home;
and be it further

Resolved: That the California Medical Associa-
tion House of Delegates instruct the California
Delegates to the American Medical Association to
introduce resolutions to implement the progress at
the American Medical Association level, and to
encourage other state and local societies to do like-
wise.

ACTION : Adopted by House.

i i i

DISSEMINATION OF FACTS RE THERMONUCLEAR
WARFARE

Resolution No. 70.

Author: Robert M. Dorn.

Representing: Los Angeles County.

Whereas, the reactions and behavior of indi-
viduals and groups, under stress, anxiety, and dan-
ger, have been well documented and represent a
form of illness; and

Whereas, the potential for thermonuclear war-
fare, by creating a persistent threat to survival, can
precipitate such an illness; and

VOL. 97, NO. 2 • AUGUST 1962

103

Whereas, certain behaviors of the populace to-
day suggest signs and symptoms of such illness: an
avoidance of objective thinking, and a tendency to
rely on rumor rather than search for facts; instances
of apathy and paralysis of action; the desire that
someone else assume responsibility; tendencies to-
ward impulsive and purposeless action bordering on
panic; an inability to observe and point out contra-
dictory statements by people in positions of author-
ity; an increase in suspicion, and loss of tolerance
for others and for social issues, indicative that indi-
viduals and groups are reacting to tensions and con-
flicts; and

Whereas, many of these trends are reversible
through the institution of corrective measures; there-
fore, be it

Resolved: That the California Medical Associa-
tion. through its officers and Council, request the
proper governmental authorities, national and state,
to institute the following measures:

1. Clarification of issues and facts raised by the
threat of thermonuclear warfare, as to survival of
individuals and groups, and the communication of
issues and facts, pro and con. to the public through
authoritative channels,

2. The assistance, to individuals and groups, to
face reality of the modern age, even if painful and
discouraging, rather than permitting dependence
on rumor, or denial of existing real dangers,

3. Utilization of intergroup and interdisciplinary
cooperation.

Only through such clarification and facts, can the
real dangers associated with thermonuclear war be
faced, without the crippling effects of illness. A well-
informed and healthy populace can exercise ade-
quate judgment.

ACTION : Referred to Committee on Disaster Med-
ical Care.

i i i

CHAMBERS OF COMMERCE

Resolution No. 71.

Author: Samuel R. Sherman.

Representing: The Council.

Whereas, the members of the House of Dele-
gates of the California Medical Association meeting
in convention in 1961 saluted the leadership of the
Chambers of Commerce “in giving voice to citizens
in all walks of life who are so vitally interested and
concerned with the maintenance of the economic
principles that stem from the freedom of the indi-
vidual to provide for his own needs through volun-
tary effort” as distinguished from socialistic ideolo-
gies, “particularly as they define the dangers of
government control of the health facilities of the
nation,” and

Whereas, physicians throughout California were
urged to join the Chambers and lend their full sup-
port to all efforts to preserve the “principles of eco-
nomic freedom and opportunity in order that
stagnation and mediocrity shall not prevail,” and

Whereas, it is particularly noteworthy that con-
siderable success has greeted the objectives noted in
1961; now, therefore, be it

Resolved: That the members of the 1962 House
of Delegates of the California Medical Association
reaffirm these principles and objectives; and be it
further

Resolved: That on this occasion when “Chamber
of Commerce Week” is being celebrated in Califor-
nia, the California Medical Association reiterate its
commendation and appreciation to the California
State Chamber of Commerce and local Chambers
of Commerce throughout the State for their unceas-
ing work on behalf of preserving our cherished
American traditions and private enterprise system;
and that copies of this resolution be sent to the
Chamber of Commerce of the United States and all
news media in California.

ACTION : Adopted by House.

iii

ADOPTIONS

Resolution No. 72.

Author: Santa Clara delegation.

Whereas, it is known that the C.M.A. Committee
on Adoptions is most knowledgeable in this field;
and

Whereas, at the direction of the House they have
printed a manual of adoptions for physicians which
prescribes the proper and ethical function of a phy-
sician in an independent adoption; and

Whereas, the chairman of the committee during
the past year has appeared before both the Califor-
nia Senate and Assembly Judiciary Committees and
offered the assistance of the Association in the study
of improvements in existing adoption procedures;
and

Whereas, it would further clarify the position
of the profession regarding certain abuses that have
been reported; be it

Resolved: That the C.M.A. House of Delegates
reemphasize the time-honored ethical position of the
profession which applies to adoptions as well as all
other activities relating to the practice of medicine
in that exploitation of patients in any manner is
condemned, including the acceptance of uncon-
scionable fees and fees for other than professional
services rendered; and be it further

Resolved: That all component societies invite
the public to report questionable practices to the

104

CALIFORNIA MEDICINE

county medical society disciplinary committees for
appropriate study and action when indicated.

ACTION: Adopted by House in above amended
form.

i i i

C.M.A. DIRECTORY

Resolution No. 73.

Author: Henry G. Morgan.

Representing: Los Angeles.

ACTION : Not adopted by House.

111

EXPANDED INDEMNITY PROGRAM

Resolution No. 74.

Author: Burt L. Davis.

Representing: Councilor.

ACTION : I'abled by House.

111

HOSPITAL STAFF PRIVILEGES

Resolution No. 75.

Author: Arthur G. Michels.

Representing: Los Angeles.

Whereas, hospital staff privileges should be
granted on the basis of skill, training and compe-
tency of the physician, rather than other conditions
or requirements; now, therefore, be it

Resolved: That the House of Delegates of the
California Medical Association go on record, as
strongly disapproving the granting or denial of
hospital staff privileges, based upon any test except
that of training, skill and competency of the physi-
cian, and specifically against test or restrictions that
pertain to religion, race or color of the applicant;
and be it further

Resolved : That a copy of this resolution be for-
warded to the Hospital Council of California, and to
all member hospitals of that Association, and hospi-
tals within the State of California.

ACTION : Adopted by House.

iii

GUIDING PRINCIPLES FOR PHYSICIAN-HOSPITAL
RELATIONSHIPS

Resolution No. 76.

Author: James C. MacLaggan.

Representing: Councilor.

Whereas, the Guiding Principles for Physician-
Hospital Relationships were adopted by the House
of Delegates February 24, 1960; and

Whereas, certain portions of these Guiding Prin-
ciples have been misinterpreted by some medical
societies and hospital staffs; and

Whereas, clear understanding of the basic
thoughts involved in these Guiding Principles is
essential for implementation by all hospital staffs;
now, therefore, be it

Resolved : That these several changes in wording
be adopted:

1. In the section entitled Role of the Physician
in the Hospital, on page two, the following shall be
added to the last paragraph: “Staff appointments
shall be reviewed and renewed annually. Informa-
tion as to other hospital staffs upon which privileges
are held shall be part of information reviewed.”

2. On page five, paragraph 5(b) entitled Medical
Procedures, the present statement shall be deleted
and the following statement adopted:

“(b) Medical Procedures

To make a qualitative analysis of medical pro-
cedures including the medical management of sur-
gical patients undertaken at the hospital and to
report to the Executive Committee its findings and
recommendations.”

3. Delete the last sentence starting on page five
and ending at the top of page six and in its stead
add: “He shall observe the concepts set forth in
Section 4 of the A.M.A. Principles of Medical
Ethics.”

4. Delete the final paragraph on page seven and
insert the following statement:

“When the Executive Committee recommends and
the hospital governing board approves the termi-
nation of a staff appointment for cause, the Ex-
ecutive Committee may, if the action is, in their
opinion, justified, answer inquiries from the Ex-
ecutive Committee of other staffs on which the
physician holds staff privileges, in writing, of the
action taken and the reasons therefor.”

ACTION : Adopted by House.

i i i

POLIO SCHOOL IMMUNIZATION LAW

Resolution No. 77.

Author: George D. Lavers.

Representing: Tulare County Medical Society.

ACTION : Withdrawn by author.

iii

MASS POLIOMYELITIS IMMUNIZATION

Resolution No. 78.

Author: John T. Saidy.

Representing: San Mateo County Medical Society.

Whereas, the fundamental interest of the Cali-
fornia Medical Association is the health care of all
of California’s citizens; and

Whereas, all three types of Sabin’s oral polio-
myelitis vaccine will be available for widespread and
large scale use by fall 1962; and

Whereas, scientifically large scale immunization
with Sabin vaccine is desirable and should be un-
dertaken in the fall and winter months; and

Whereas, the present Salk vaccine program is
temporarily achieving satisfactory control of polio
obviating any urgent need for immediate immuniza-
tion with Sabin vaccine; now, therefore, be it

VOL. 97, NO. 2 • AUGUST 1962

105

Resolved: That this House of Delegates instruct
the Council of the C.M.A. to immediately cause to
be planned a coordinated C.M.A. and component
society-sponsored immunization campaign; and be
it further

Resolved: That all professional societies and
agencies such as the American Academy of Pedi-
atrics, Academy of General Practice, the Depart-
ment of Public Health, etc. be immediately advised
of this plan so that their advice and cooperation
may be enlisted and so that all may know now of
the program for this fall. Meanwhile, the present
program of Salk immunization should be encour-
aged and supported.

ACTION: Adopted by House in above amended
form.

ill

SPORTS MEDICINE

Resolution No. 79.

Author: L. F. Armanino.

Representing: San Joaquin County Medical Society.

Whereas, there is increasing concern by the gen-
eral public, by those engaged in various athletic
programs and by the medical profession regarding
the safety, health and care of the athlete; and

Whereas, the American Medical Association has
organized a committee on the Medical Aspects of
Sports, and 44 of the State Medical Associations
now have special committees studying the matter of
safety in school athletics; and

Whereas, this concern is not limited to school
athletics, hut with all forms and types of sports,
amateur and professional; now, therefore, be it
Resolved: That the Council of the California
Medical Association consider the establishment of
an appropriate C.M.A. committee or subcommittee
on the “Medical Aspects of Sports.”

ACTION : Adopted by House.

i i i

TRANSPORTATION OF STRETCHER CASES BY
COMMERCIAL AIRCRAFT

Resolution No. 80.

Author: Milo A. Youel.

Representing: San Diego County.

Whereas, passenger transportation by air has
become a major form of travel; and

Whereas, this form of transportation to distant
points is encouraged by the various commercial air-
line companies; and

Whereas, certain passengers who become injured
or ill while away from their residence will desire to
return home for medical care or convalescence; and
Whereas, many of the commercial airlines oper-
ating in the United States often do not accept wheel-
chair or stretcher cases; and

Whereas, many types of wheelchair and stretcher
cases can be safely and, in fact, best transported by
air; now therefore be it

Resolved: That this House of Delegates ask the
A.M.A. to study and make recommendations on this
subject.

ACTION : Adopted by House.

FORMATION OF NEW COUNCILOR DISTRICTS

Resolution No. 81.

Author: Richard D. Miller.

Representing : Los Angeles.

Whereas, the Council of the California Medical
Association envisions the absorption of some 2,200
Osteopathic Physicians into the ranks of regular
medicine; and

Whereas, the disproportionate representation of
the Southern Counties in the Council of C.M.A. will
he increased by the absorption of 1,800 out of the
2,200 Osteopathic members; now, therefore, be it
Resolved : That appropriate measure be immedi-
ately taken to formulate Councilor Districts through-
out the entire state according to C.M.A. member
population; and be it further

Resolved: That starting in 1964 there shall be
direct vote in each Council or District by the C.M.A.
members of that district for their particular C.M.A.
Councilor; and be it further

Resolved: That one Councilor will represent
1,000 C.M.A. members; and be it further

Resolved: That redistricting be done every three
(3) years.

ACTION : See Resolution No. 63.

iii

CONTRACT BY CALIFORNIA MEDICAL ASSOCIATION

Resolution No. 82.

Author: Allyn J. McDowell.

Representing: Los Angeles.

ACTION : Not adopted by House.

iii

PARTISAN PRESENTATION

Resolution No. 83.

Author: Allyn J. McDowell.

Representing: Los Angeles County.

(Reference Committee No. 4 considered Resolu-
tion Nos. 83, 84 and 85 as a group and offered a
substitute resolution in place of all three, as below.)

Resolved: That the C.M.A. House of Delegates
request each county medical society to:

1. Establish liaison committees with the osteo-
pathic group in each county for implementation of
the merger agreement and establishment of neces-
sary professional contact.

106

CALIFORNIA MEDICINE

2. Establish means of assessing the standard of
care rendered by each osteopath practising in that
county.

3. Offer to serve in an advisory capacity to the
California College of Medicine for the evaluation of
each candidate for the M.D. degree. While recom-
mendations of the county medical societies are not
binding on the California College of Medicine, they
serve as a guide for the awarding of the M.D. degree.

ACTION : Adopted by House.

1 1 i

EXPEDIENT PROMISES

Resolution No. 84; see Resolution No. 83.

Author: Allyn J. McDowell.

Representing: Los Angeles.

i i *

MORAL RESPONSIBILITY

Resolution No. 85; see Resolution No. 83.

Author: Allyn J. McDowell.

Representing: Los Angeles.

lit

REPORTING OF EPILEPSY

Resolution No. 86.

Authors: Stanley Skillicorn and C. Gerald Scarborough.
Representing: Santa Clara County Medical Society.

Whereas, this House of Delegates unanimously
voted in 1960 for Resolution 54 covering suggested
changes in California law regarding mandatory re-
porting of Epilepsy; and

Whereas, the Traffic Safety Committee of the
California Medical Association has, despite this
direction of the House of Delegates, recently pro-
posed that all doctors abide by the presently stated
law; and

Whereas, the Traffic Safety Committee and the
Council have, it seems, inadvertently, ignored the
direction of the House of Delegates; now, therefore,
be it again

Resolved: That the Traffic Safety Committee of
California Medical Association be directed to study
the problem of Epilepsy as a reportable disease, to
seek methods to make any reporting of medical con-
ditions, including alcoholism, as well as epilepsy,
equitable and nondiscriminatory.

ACTION : Adopted by House.

1 i 1

ACCREDITED INTERNS AND RESIDENTS IN
NON-UNIVERSITY HOSPITALS

Resolution No. 87.

Authors: Thomas N. Foster and C. Gerald Scarborough.
Representing: Santa Clara County Medical Society.

Whereas, there are independent County hospitals
in California with excellent case material and Visit-
ing Staffs capable of training of Interns and Resi-
dents in patient care; and

Whereas, a shortage of such Doctors is evident
and increasing in many parts of the country; and
Whereas, Accreditation Commission and Spe-
cialty Boards are forcing assimilation of these pro-
grams into University programs, thus decreasing
the ultimate number of programs and Doctors
trained in patient care; now, therefore, be it

Resolved: That the C.M.A. and its delegates to
A.M.A. continue efforts to support independent
teaching programs where properly conducted, in
addition to University programs, so that the number
of Doctors trained in patient care will be increased
rather than decreased.

ACTION : Adopted by House.

iii

C.P.S. REFERENCE COMMITTEE

Resolution No. 88.

Author: Leon P. Fox.

Representing: Santa Clara County Medical Society.

ACTION : Not adopted by House.

iii

PRIVILEGED COMMUNICATION FOR PHYSICIANS

Resolution No. 89.

Author: Robert L. Dennis.

Representing: Santa Clara County Medical Society.

Resolved: That the House of Delegates of the
California Medical Association recognizes the need
for and advocates legislative action that will grant
privileged communication between physicians and
patients in matters pertaining to diagnosis, therapy,
and patients’ care.

ACTION: Adopted by House.

iii

C.P.S. -COUNTY PREPAYMENT PLANS

Resolution No. 90.

Author: Thomas Elmendorf.

Representing: Butte-Glenn County.

Whereas, the House of Delegates of the Califor-
nia Medical Association has previously proclaimed
the policy of local programs tailored to local needs
for tax-supported medical care; and

Whereas, the Glenn County-C.P.S. prepayment
contract for Welfare recipients is a successful im-
plementation of such policy; and

Whereas, other counties are currently attempting
to establish their own local programs; and

Whereas, there are indications that the State De-
partment of Social Welfare desires to discontinue
the Glenn County-C.P.S. program as well as look
with disfavor upon other local proposed programs;
now, therefore, be it
Resolved : That

1. The House of Delegates reaffirm its previously
avowed policy of local programs tailored to local
needs.

VOL. 97. NO. 2 • AUGUST 1962

107

2. Instruct the Council of the California Medical
Association through its appropriate committees to
exert maximum effort to execute this policy.
ACTION: Adopted by House.

i i i

MEDICAL CARE OF THE AGED

Resolution No. 91.

Author: Allan K. Briney.

Representing: Executive Committee, L.A.C.M.A.

Whereas, the President of the United States con-
siders Medical Care of the Aged under Social Secur-
ity as his number one domestic affairs issue, and
Whereas, the President will deliver a major ad-
dress on this subject from Madison Square Garden
in New York on May 20, and

Whereas, the tenor of his address can well be
anticipated, therefore, be it

Resolved : That the California Medical Associa-
tion take immediate steps to encourage the American
Medical Association to present the Edward Annis,
M.D., film on a national television network program
on May 20, 1962, following the President’s address;
and be it further

Resolved: That the California Medical Associa-
tion sponsor the showing of this film on television
to obtain statewide coverage following the Presi-
dent’s address on May 20, if the American Medical
Association does not comply with this resolution;
and be it further

Resolved : That the California Medical Associa-
tion encourage County Associations to inform the
public in their county of the Edward Annis, M.D.,
program.

ACTION : Adopted by House.

iii

EMERGENCY RESOLUTION

Author: Samuel R. Sherman.

Representing: The Council.

Whereas, California is highly honored front time
to time by the election of one of its physicians to the
highest office that American medicine can bestow,
namely, the presidency of the American Medical
Association; and

Whereas, this great honor has not heretofore
been recognized in its proper magnitude by this
House of Delegates; now, therefore, be it

Resolved: That the House of Delegates of the
California Medical Association hereby declares that
all former presidents of the American Medical Asso-
ciation from California who are not officially desig-
nated as members of this House of Delegates shall
be declared as Honorary Past Presidents of the
California Medical Association and be cloaked with
all the honors and privileges granted to past presi-
dents of this association ; and be it further

Resolved: That the designation of Honorary
Past President be conferred forthwith on Doctor
Dwight H. Murray.

ACTION : Adopted by House.

AMENDMENTS TO CONSTITUTION

Amendments to the Constitution of the California
Medical Association are required to lie on the table
for one year before being voted upon.

Seven such amendments were introduced in the
1961 House of Delegates and thus were subject to
vote in 1962. The 1961 amendments and the actions
taken upon them follow:

1961 AMENDMENTS

CONSTITUTIONAL AMENDMENT No. 1

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Article I, Section 5, of the Con-
stitution of the California Medical Association shall
be amended, by adding a new sentence at the end
of the present section reading as follows:

“Notwithstanding the foregoing, one charter may
be issued to a component society that is not lim-
ited as to geographical area or which overlaps the

area covered by one or more existing component
societies.”

ACTION : Adopted by House.

i i i

CONSTITUTIONAL AMENDMENT No. 2

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Article III, Part B, Section 10,
of the Constitution of the C.M.A. shall he amended
by deleting the word “ten” in the first sentence of
the section and substituting therefor the word
“eleven” and by adding the following sentence as a
separate subparagraph of said section:

“District No. 11, consisting of any society which
is not limited as to geographical area, or the area
of which overlaps the area covered by one or more
existing component societies; such society and its
members shall not be considered to be members of
any other councilor district.”

ACTION : Adopted by House.

108

CALIFORNIA MEDICINE

CONSTITUTIONAL AMENDMENT No. 3

Aulhor: James MacLaggan.

Representing: San Diego County.

ACTION : Not adopted by House.

iii

CONSTITUTIONAL AMENDMENT No. 4

Author: Los Angeles delegation.

ACTION: Not adopted by House.

Y Y Y

CONSTITUTIONAL AMENDMENT No. 5

Author: Alameda-Contra Costa delegation.

Resolved: That Article IV. Section 3 of the
C.M.A. Constitution be amended to read: “The
Council, on recommendation of a component soci-
ety, may grant leaves of absence to active and asso-
ciate members who are seriously ill, etc. . . .”
ACTION: Adopted by House.

Y i 1

CONSTITUTIONAL AMENDMENT No. 6

Author: Jerome Klingbeil.

Representing: Los Angeles County (Long Beach).

Resolved : That the California Medical Associa-
tion initiate changes in its Constitution and By-
laws which will permit any established district of
a county society to withdraw from that county soci-
ety and become a direct component part of the Cali-
fornia Medical Association; and be it further

Resolved : That the California Medical Associa-
tion amend its Constitution and Bylaws as follows:

A. Article I, Section 4 — Definition of Component
Societies

Component societies include all county medical
societies (which may cover one or more counties)
or any established component district of at least 300
members of a county society which has exercised
option to withdraw from that county society and set
up a separate component society, heretofore or here-
after, chartered by this Association.

(B.—See ACTION below.)

C. Article III, Section 7(a) — Issuance and Revocation
of Charters

The House of Delegates shall issue charters to
medical societies of any county, any component so-
ciety of at least 300 members which has exercised
its option to become autonomous or to any group of
counties deemed eligible which have made proper
application therefor.

ACTION : Paragraphs A and C were adopted by
House; Paragraph B, on component society charters,
was not adopted by House.

CONSTITUTIONAL AMENDMENT No. 7

Author: Ian Macdonald.

Representing: Los Angeles County.

ACTION : Not adopted by House.

1962 AMENDMENTS

Six proposed amendments to the Constitution
were introduced in the 1962 House of Delegates.
They were reviewed by Reference Committee No. 4
of the 1962 House of Delegates and will also be
reviewed by Reference Committee No. 4 of the 1963
House. In certain instances the 1962 Reference Com-
mittee made certain specific recommendations which
were adopted by the House.

CONSTITUTIONAL AMENDMENT No. 1

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Article I, Section 3 of the Con-
stitution of the California Medical Association as
now written be deleted and this section to read as
follows:

“This Association is an organization composed of
the component medical societies and their members,
the House of Delegates, the Council, the Scientific
Board, the Scientific Assembly, Bureaus, Commis-
sions and Standing Committees.”

i i 1

CONSTITUTIONAL AMENDMENT No. 2

Author: Samuel R. Sherman.

Representing: the Council.

Resolved: That Article III, Section 1, be
amended by deleting the word “and” at the end
of subsection (c), and by adding a new subsection
(d) to read as follows:

“(d) Ex-officio with the right to vote, eighteen
(18) members of the Scientific Board selected as
provided in the Bylaws, and”

The present subsection (d) shall be redesig-
nated (e).

ill

CONSTITUTIONAL AMENDMENT No. 3

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Article III, Part B. Section 9,
of the Constitution of the California Medical Asso-
ciation shall be amended by inserting a new
subparagraph (c) and redesignating the present
subparagraph (c) as (d), and the present subpara-
graph (d) as (e). The new subparagraph (c) shall
be inserted immediately after subparagraph (b)
and shall read as follows:

VOL. 97, NO. 2 • AUGUST 1962

109

“(c) One (1) member of the Executive Com-
mittee of the Scientific Board to be elected by the
Executive Committee of that body from represen-
tatives of the scientific sections or members-at-
large.”

iii

CONSTITUTIONAL AMENDMENT No. 4

(Printed with Action following Constitutional
Amendment No. 5)

iii

CONSTITUTIONAL AMENDMENT No. 5

Author: Dwight L. Wilbur.

Resolved: That Article III, Part A, Section 1,
be amended by deleting the word “and” at the end
of subsection (c), and by adding a new subsection
(d) to read as follows:

“(d) Ex-officio, with the right to vote, the mem-
bers of the Scientific Board, and”

The present subsection (d) should be redesig-
nated as (e) .

ACTION: The House adopted a motion directing
the Council to appoint a committee to make a study
and submit a report to the delegates and alternates
at least thirty days before the next annual meeting
concerning the membership requirements, voting
procedures and organization of the scientific sections
contemplated in Constitutional Amendments Nos. 1,
2, 3 and 5.

iii

CONSTITUTIONAL AMENDMENT No. 4

Author: Los Angeles delegation.

Whereas, the Council of the C.M.A. is an im-
portant group in carrying on the activities of the
C.M.A. ; and

Whereas, it is important that the members of
the Council be responsive to the desires of the ma-
jority of the members of the C.M.A.; and

Whereas, a democratic organization provides a
vote to all its members ; now, therefore, be it

Resolved: That the Constitution of the C.M.A.,
Article III, Part B, Section 11, be amended to read
as follows:

“Section 11 — Election of Councilors

“District Councilors shall be elected by the vote
of the members, entitled to vote, from each District,
in the manner and at the time specified in the By-
laws.”

and be it further

Resolved: That the Bylaws of the C.M.A. be
amended to provide for the election of District
Councilors in accordance with this Constitutional
amendment.

ACTION: Constitutional Amendment No. 4 (to-
gether with Bylaiv Amendment No. 12 printed under
1962 Bylaw Amendments) was referred to a special

ad hoc committee to be appointed by the Speaker
with instructions to study the proposals and make
a report to the House of Delegates at its next annual
session.

CONSTITUTIONAL AMENDMENT No. 6

Author: Allyn J. McDowell.

Representing: Los Angeles.

Resolved: That the Constitution of the Califor-
nia Medical Association be amended by adding to
Article I, Section 2, the following:

“This Association shall not have the right to enter
into a contract with any person, firm, or agency of
any kind with respect to the practice of medicine or
fees for such practice.”

BYLAW AMENDMENTS

Four proposed amendments to the Bylaws intro-
duced in the 1961 House of Delegates were, on
recommendation of the Reference Committee and
vote of the House, deferred for consideration until
1962.

The Reference Committee also suggested that a
special committee be established to review all such
deferred amendments. This committee was estab-
lished by the Council and reviewed all amendments
to the Constitution and Bylaws which related to the
structure of the Association.

Shown below is the action taken on all proposed
amendments to the Bylaws introduced in 1961 and
deferred for action in 1962.

ill

1961 BYLAW AMENDMENTS

BYLAW AMENDMENT No. 1

Author: Samuel R. Sherman.

Representing: The Council.

ACTION : Withdrawn by author.

lit

BYLAW AMENDMENT No. 6

Author: James MacLaggan.

Representing: San Diego County.

ACTION : Not adopted by House.

iii

BYLAW AMENDMENT No. 10

Author: Los Angeles delegation.

ACTION: Not adopted by House.

iii

BYLAW AMENDMENT No. 15

Author: Los Angeles delegation.

ACTION : Not adopted by House.

CALIFORNIA MEDICINE

1962 BYLAW AMENDMENTS

A total of 14 amendments to the Bylaws was
offered to the 1962 House of Delegates. Bylaw
amendments may be acted upon after lying on the
table for 24 hours, hence all these were eligible for
vote at the second meeting of the House.

However, in two instances the House voted that
certain Bylaw amendments be referred to a special
ad hoc committee for study and voted on in 1963.

Shown below are all amendments to the Bylaws
introduced this year, with a report of the action
taken by the House.

■fii

BYLAW AMENDMENT No. 1

Author: Samuel R. Sherman.

Representing: The Council.

Resolved : That Chapter II, Section 10, Subsec-
tions (c) and (d), and Chapter III, Sections 1. 2,
3 and 4 of the Bylaws of the California Medical
Association shall be amended as follows:

Chapter II, Section 10

This section is presently entitled: “Termination
of Membership.” Its title shall be amended to read:
“Termination, Suspension or Probation of Mem-
bership.”

Section 10, Subsection (c), is presently entitled:
“By Revocation of Physician and Surgeon’s Cer-
tificate.” This title shall be amended to read: “By
Revocation, Suspension or Probation of Physi-
cian and Surgeon’s Certificate.” A sentence shall be
added at the end of the present subsection to read
as follows: “ Receipt of written evidence that the
Board of Medical Examiners has found a member
guilty of a disciplinary charge but has suspended
judgment and placed him on probation for a stated
length of time, shall thereupon cause the member
to be a probationary member of the Association for
a concurrent period of time.”

Section 10, Subsection (d), shall be amended by
inserting the word “probation” after the last comma.
The last part of that section would then read:
“. . . shall be subject to censure, probation, suspen-
sion or expulsion from his society by such compo-
nent society.”

Ch apter III, Section 1 — Disciplinary Procedure for
Component Societies

The opening sentence shall be amended to insert
the word “probation” after the first comma. It
would then read: “The procedure to be followed
by each component society with respect to the cen-
sure, probation, suspension or expulsion of a mem-
ber shall be:”

Subsection (2)(b) — Creation of Judicial Councils;

Secretary’s Duties; Preparation of Charges to
Judicial Council

This subsection shall be amended by adding the
following language at the end thereof: “In any com-
ponent society having 200 or less active members,
the governing board may find that in an unusual
case it is unable to act as a Judicial Council because
of close personal or professional involvement of
members of the Judicial Council with the accused or
that the facilities and personnel available to the
society are inadequate to impartially and effectively
investigate, present and decide an involved or com-
plicated complaint. The governing board may pass
a resolution setting forth the facts and request the
California Medical Association councilor represent-
ing the district in which the county society is
located, and the California Medical Association
Council, to appoint a five-man district Judicial
Council to hear the particular pending case or cases,
and ask the California Medical Association to pro-
vide staff and financial assistance to investigate and
present the case for the county society. Three mem-
bers of the district Judicial Council shall constitute
a quorum. In such instances, the charges shall be
served or mailed in the same manner as is provided
for a regular county Judicial Council proceeding,
however, the district Judicial Council chairman shall
be consulted concerning the fixing of the time, date
and place of hearing.”

Subsection (2)(d)

This subsection shall be renumbered subsection
(2)(c).

Subsection (2) (c)

This subsection shall be renumbered subsection

(2) (d) .

Subsection (3)

The present subsections (3) and (4) shall be
repealed and there shall be substituted, a new sub-
section numbered (3), entitled: “Service of Charge
Upon Accused and Fixing Time and Place of Hear-
ing.” This section shall read as follows:

“If the Judicial Council determines that further
action, with respect to said charges, shall be taken,
the Council must fix a time and place for a hearing
of said charges. Within fifteen (15) days after such
decision, a copy of the charges, together with a
written notice of the time and place for the hearing,
shall be served upon the complainant, the accused
and the Judicial Commission of the California Med-
ical Association. Personal delivery or notice by reg-
istered mail shall be addressed to the accused either
at his last known office or last known residence.

“The time so set for a hearing shall be not less
than fifteen (15) days after the accused has been

VOL. 97, NO. 2 • AUGUST 1962

111

served as aforesaid, with a copy of the charges and
with the notice of the time and place set for the
hearing; said hearing must be held within the
county in which the accused holds his county society
membership. The hearing before the Judicial Coun-
cil must actually commence within six months from
the date of the filing of written charges. Failure to
comply with this requirement shall constitute an
automatic dismissal of the charges.

“The Judicial Council shall formally recognize
who will prosecute the complaint or appoint some-
one to do so and grant the appointee necessary
authority to make appropriate investigation and
obtain help of counsel where needed. It shall be the
duty of any member of the Association requested
to testify to do so. Failure to testify without an ex-
cuse satisfactory to the Judicial Council shall be con-
sidered unprofessional conduct.’

Subsection (4)

New subsection (4) shall be entitled: “'Appoint-
ment and Duties of a Referee ,” and shall read as
follows :

“The Judicial Commission of the California Med-
ical Association when it receives a copy of the notice
that a disciplinary proceeding is pending before any
component society, may of its motion, and shall
upon the request of such component society or of
the member or members thereof the subject of any
such disciplinary proceeding, appoint a referee who
may, but need not be. a member of the California
Medical Association, and shall cause the secretary
of the California Medical Association to notify the
secretary of such component society of such ap-
pointment. The referee so appointed shall preside
at the hearing of said charges and shall make all
decisions concerning the admission or rejection of
testimony or other evidence and procedure. The
referee shall not. however, have any voice nor par-
ticipate in any manner in the determination by the
Judicial Council of the disposition of the charges.
During the hearing the referee shall perform all
duties normally performed by the presiding officer
of the Judicial Council.”

Subsection (5) — Right of Accused to Answer; Time to
Answer; Formal Requirements

The following statement shall be inserted at the
end of this subsection: “Failure of the accused to
appear or be represented at the hearing may be con-
sidered prima facie evidence of the truth of the
charges. When clear and convincing proof of them
is presented, a verdict may be rendered. The ac-
cused may be represented by another member of the
Association or by legal or other counsel.”

Subsection ( 6 )

The previous subsection (6) is repealed and this
new subsection shall be entitled: “Rules Governing
Hearing.”

Present subsections (10) (c) entitled: “Technical
Rules of Evidence Not to Govern Disciplinary Hear-
ings,” and (10) (d) entitled: “Members Agree That
No Cause of Action Shall Accrue,” shall become
subsections (6) (a) and (b) and read as follows:

“(a) Technical Rules of Evidence Not to Govern
Disciplinary Hearings. All hearings with respect to
the disposition of charges against a member of a
component society shall be held and conducted in
such manner as to ascertain all the facts fairly to
the accuser and accused, eliminating all formal or
technical rules and requirements which ordinarily
pertain to judicial proceedings.”

“(b) Members Agree That No Cause of Action
Shall Accrue. Any person so charged, censured, sus-
pended, or expelled shall have no claim or cause of
action against this Association, a component society
or any member, director, councilor or officer, thereof
by reason of such charges, or the hearing or the
consideration thereof or censure, suspension or ex-
pulsion therefor.”

Subsection (6) (c) shall be entitled: “Challenge
or Disqualification of Council Member ” and read
as follows:

“The accused shall have the right at the begin-
ning of the hearing to challenge the impartiality of
any member of the Council and may exercise this
right by stating to the referee the name of the person
challenged and the reasons for the challenge. Any
member of the Council may disqualify himself to
hear a particular case by informing the referee that
he believes there exists substantial reason in his
own mind that would prevent him from being com-
pletely impartial and objective in his consideration
of a particular case. In both such instances, the
official record should reflect that the referee granted
the challenge or the request to be disqualified.”

Subsection (6) (d) shall be entitled: “Record of
Proceedings ” and shall read as follows:

“A record of the hearing proceedings including
the testimony, documents and rulings shall be made
either by a competent shorthand reporter or by
recording equipment, if agreeable to both parties.
The expense of recording the proceedings shall be
borne by the county society except in those cases
referred to in subsection (2) (b) where a county
society requests the appointment of a district Judi-
cial Council and asks for financial assistance from
California Medical Association. The typewritten
transcript of the testimony, the documents intro-
duced and the written decision of the Judicial

112

CALIFORNIA MEDICINE

Council shall constitute the record of the entire
proceedings. The secretary shall, upon receipt from
the accused of a sum sufficient to defray the pro-
portionate cost thereof, cause a copy or copies of
such record to be transcribed, certified and fur-
nished to the accused.”

Subsection (6) (e) shall be entitled: “Right of
Parties to Be Heard 1,” and shall read as follows:

“The Judicial Council shall give ample opportu-
nity both to the accuser and the accused to be heard
in person and to present all testimony, evidence, or
proofs which the accuser or the accused may deem
necessary, provided that the Council may reject all
testimony, evidence, or proofs, which in the judg-
ment of the Council are immaterial, irrelevant or
unnecessarily repetitious.

“Both parties shall be allowed necessary time to
present the matter in an orderly fashion. The com-
plainant or the society or the person appointed by
the Judicial Council shall first present the facts in
support of the complaint starting with a copy of the
charges, together with a statement of all relevant
facts concerning the fixing and calling of the meet-
ing and the mailing of the notice to the accused,
and any answer that has been filed. A copy of the
charges and any documentary evidence to be intro-
duced shall be made available to all parties con-
cerned and the members of the Council. The referee
may allow any witness to be reasonably cross-
examined. Questions aimed at clarifying or estab-
lishing essential details may be asked by the Coun-
cil. An equal opportunity to present testimony and
documents to answer or explain the charges shall
be allotted the accused. After the initial presenta-
tion of the facts by each side, opportunity shall be
afforded for any necessary rebuttal. After all ques-
tions have been satisfied, the Council may ask each
side to give a brief summary of the essential facts.
If further pertinent written information would be
helpful to the Council, they may request it.”

Subsection (7) — Decision of Council; When Must Be
Written; Rules Governing Vote of Council

This new subsection shall take the place of the
previous subsection (7) and shall read as follows:

“A simple majority shall constitute a quorum.
A member of the Judicial Council not present at the
hearing for the entire time shall not be entitled to
vote with respect to the disposition of the charges
or be considered part of the quorum. Appropriate
recesses or adjournment of the hearing may be per-
mitted by the referee.

“The Judicial Council, by at least a two-thirds
affirmative vote of all members present at the hear-
ing for the entire time, may vote to exonerate or to
censure, suspend, place on probation or expel the
accused member if he be found guilty of one or

more of the charges presented. Prior disciplinary
action may not be considered in determining
whether the accused is guilty of one or more of the
charges, but may be considered in assessing an ap-
propriate sanction. Ordinarily, the action taken
may be expressed in the form of a resolution. The
vote may be taken by written ballot or by roll call.
Failure of two-thirds of those eligible to vote to
agree as to guilt shall act automatically as a dis-
missal of the charge. The Judicial Council shall
render its decision as to guilt in writing not more
than thirty days after the close of the hearing or
the receipt of all supplementary written informa-
tion requested by it. The written decision shall
briefly and clearly set forth the particular acts, con-
duct or omissions for which an accused is found
guilty.

“Within ten days after the decision of the Judi-
cial Council is rendered, the secretary to the Judi-
cial Council shall transmit a copy of the decision to
the accused, the secretary of the society and the
secretary of this Association.”

Subsection (8) — Suspension; Reinstatement of
Suspended Member; Probation

This new subsection (8) shall repeal and take the
place of the previous subsection (8) and shall read
as follows:

“A censure shall consist of an oral or written ad-
monition and imposition of appropriate restrictions.

“A member may be suspended by imposing a
limited period, not to exceed five years, during
which he shall have no rights or privileges to vote,
hold office and participate in the activities of the
society. Recommendations to the county society Ex-
ecutive Committee concerning eligibility for society
insurance benefits and payment of dues shall be spe-
cifically made in the decision of the Judicial Coun-
cil in each case.

“The Judicial Council may impose a fixed period
of probation or defer the effective date of a suspen-
sion or expulsion. The conditions of probation and
the privileges of membership during probation shall
be fixed by the decision of the Judicial Council.

“If the accused violates any of the conditions of
probation or of suspension, the Judicial Council
may terminate the probation and order the suspen-
sion or expulsion to become effective on a date
specified.

“At the end of the probation or suspension, on
application of the disciplined member, the Judicial
Council shall consider the quality of his behavior
during his suspension or probation, and shall deter-
mine whether he shall be reinstated to membership
in good standing or the period of suspension or
probation extended. This decision of the Judicial
Council may be voted, expressed and distributed in

VOL. 97, NO. 2 • AUGUST 1962

113

the same manner as is provided for the original
decision.

“After the expiration of one year from the date
of termination of membership, application for elec-
tion to membership may be made to the society in
the same manner as a new applicant for member-
ship.”

Subsection (9) — Judicial Council’s Decision Final;

Subject to Appeal

This new subsection (9) shall repeal and take the
place of the previous subsection (9), and shall read
as follows :

“The decision of the Judicial Council shall be-
come final and effective ten days after the expiration
of the time limit within which an appeal may be
taken to the Judicial Commission of the Association.
Filing an appeal with the secretary of this Associa-
tion shall automatically stay the execution of the
decision of the Judicial Council until written notice
of the action of the Judicial Commission of this
Association with respect to the appeal has been re-
ceived by the secretary of the component society
from which the appeal is taken.”

Subsection (10)

Subsection (10) shall be repealed.

Chapter III, Section 2 — Procedure for Appeal to
Judicial Commission

The first and second sentences of this section shall
be deleted and the following inserted:

“A member of a component society censured, pro-
bated. suspended or expelled by his county society
may appeal from the action of such component so-
ciety to the Judicial Commission of this Association
within the period of two months succeeding the date
of such censure, probation, suspension, or expulsion.
Appeals shall be in writing and be filed in the office
of the secretary of the Judicial Commission at the
California Medical Association office, specifically
setting forth the procedures, findings, conclusions
or disciplinary action or any part thereof that is
questioned or challenged. Those matters not chal-
lenged will be presumed to be admitted as factual
and reasonable.”

The third sentence beginning: “Said appeal shall
be accompanied by . . .” and all that follows shall
remain as is.

Chapter III, Section 3 — Rules Governing Appeals

After the present first sentence, the following sen-
tence shall be added: “The appellant may be repre-
sented by counsel and may submit oral and written
material in support of the matter specifically ques-
tioned or challenged in his appeal. The county so-

ciety representative and its counsel may appear in
support of the decision of the Judicial Council and
may submit written and oral statements.”

The second sentence and all that follows in this
section shall remain as is.

Chapter III, Section 4

There shall be adopted a new section 4, entitled :
“ Investigations and Opinions Concerning Applica-
tion of the Principles of Medical Ethics ,” to read as
follows:

“In addition to the powers granted to Judicial
Councils in section 1 of this chapter, and to the
Judicial Commission in sections 2 and 3, to review
specific charges against individuals, they shall have
the power to investigate and supervise the ethical
professional deportment of the membership of the
Association and shall make periodic recommenda-
tions for improvement of professional conduct and
interpret the meaning and application of the Princi-
ples of Medical Ethics. Appropriate investigation or
study may be initiated by a formal complaint or
by a Judicial Council or the Judicial Commission.
The final recommendations should be submitted in
the form of a report or bulletin.

“After approval by the appropriate county society
executive board or the Council of the California
Medical Association, the findings and recommenda-
tions shall be binding on all members of the Asso-
ciation after they are published in the official county
bulletin or journal of the Association.”

ACTION : Adopted by House.

BYLAW AMENDMENT No. 2

Author: Samuel R. Sherman.

Representing: The Council.

ACTION : Withdrawn by author.

BYLAW AMENDMENT No. 3

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Chapter V, Section 2, of the
Bylaws be amended to read:

“Commencing with the 1964 regular session of
the House of Delegates, each component society
shall be entitled to two delegates plus one delegate
for each 100 active members or major fraction
thereof, exclusive of the first 100, according to its
membership as of the first day of September of the
preceding year. Every six years subsequent to 1964
the Council of the California Medical Association
shall automatically review the size of the House of
Delegates and make appropriate recommendations.”

ACTION: Adopted by House.

114

CALIFORNIA MEDICINE

BYLAW AMENDMENT No. 4

Author: Samuel R. Sherman.

Representing: The Council.

Resolved : That Chapter VII, Section 1, Subsec-
tion (a), Item 2, of the Bylaws be amended to read
as follows:

“2. Committee on Aging and Related Health Fa-
cilities.”

ACTION: Adopted by House.

i i i

BYLAW AMENDMENT No. 5

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Chapter VII, Section 9, sub-
section (a) of the Bylaws be amended by adding
the following paragraph to the present subsection
(a) :

“It shall refer for investigation and review to the
Committee on Mediation and Medical Care Insur-
ance all complaints received from medical societies
in which the component society requests a review
by the committee or any case where the component
society finds it is unable or unwise for its mediation
committee to review the case. Orderly procedures
to carry out this function shall be established. The
findings and recommendations of the committee
concerning each case reviewed shall be reported to
the component medical society, the parties to the
dispute, this commission and the Council.”

ACTION: Adopted by House.

i i i

BYLAW AMENDMENT No. 6

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Chapter VII, Section 1, of the
Bylaws be amended by deleting therefrom the pres-
ent subsection (d) and substituting therefor the
following:

(d) Bureau on Communications, responsible for
the activities of and through which shall report such
committees as may be named by the Council to func-
tion in activities bearing on the relations of the
Association with its own members and with other
individuals or organizations.”

ACTION : Adopted by House.

ill

BYLAW AMENDMENT No. 7

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Chapter V of the Bylaws be
amended by adding thereto a new Section 13, to
read as follows:

“13. Introduction of Business

“All business to come before the House of Dele-
gates shall be presented in writing and shall be sent
to the Secretary at the headquarters office at least 30
days in advance of the first meeting of any session.
The Secretary shall then send copies of all such
business to the members of the House of Delegates
at least 15 days in advance of the first meeting.

“Business which is not presented within this time
limit may be presented in writing to the Secretary
as late as seven days before the first meeting of the
House of Delegates. Copies of such business shall
be made available to the members of the House of
Delegates in advance of the first meeting.

“Any business presented less than seven days be-
fore the first meeting shall be reviewed by the
Council and, if found to be of an emergency nature,
shall be approved for introduction into the House
of Delegates.

“Any business presented on the floor of the House
of Delegates shall be referred to a special committee
of the House of Delegates, to be appointed by the
Speaker and to consist of at least five members of
the House of Delegates, which shall review such
business and, if approved, recommend its introduc-
tion as emergency business.”

ACTION : Adopted by House.

i i i

BYLAW AMENDMENT No. 8

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Chapter VII, Section 3, Subsec-
tion (c) of the Bylaws be amended by the deletion
of the last sentence of that Subsection, which reads:

“. . . . The members of the Commission on Public
Policy shall be selected from the members of the
Committee on Legislation and the members of the
Committee on Public Relations.”

ACTION : Adopted by House.

i i i

BYLAW AMENDMENT No. 9

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Chapter VII, Section 9, Subsec-
tion (d) of the Bylaws be amended by deleting
therefrom the present Subsection (d) and substitut-
ing therefor the following:

“(d) The Bureau on Communications shall study,
investigate, and conduct approved association ac-
tivities concerning communications and relations
between the public and the medical profession and
within the profession itself. It shall allocate to vari-
ous committees for which it may be responsible

VOL. 97, NO. 2 • AUGUST 1962

115

particular projects within their respective fields. It
shall direct and coordinate the activities of its com-
mittees.”

ACTION : Adopted by House.

111

BYLAW AMENDMENT No. 10

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Chapter VII, Section 1, be
amended by deleting subsections (e) and (f) and
by redesignating the present subsection (g) as (e)
and the present subsection (h) as (f) ; and be it
further

Resolved: That Chapter VII, Section 9 be
amended by deleting subsections (e) and (e) (1)
and redesignating subsection (f) as (e).

ACTION : Adopted by House.

i i i

BYLAW AMENDMENT No. 11

Author: Samuel R. Sherman.

Representing: The Council.

Resolved : That Chapter IV of the Bylaws of the
California Medical Association shall be amended by
repealing the present Chapter IV and inserting in its
stead the following:

“CHAPTER IV— SCIENTIFIC AND EDUCATIONAL
ACTIVITIES OF THE ASSOCIATION

“Section 1 — Scientific Board
“The Scientific Board shall be responsible for all
educational and scientific activities of the Associa-
tion including the annual and other scientific assem-
blies, continuing medical education, the Associa-
tion’s official journal, California Medicine, and
shall serve as a source of scientific information for
members of the Association, the House of Delegates,
the Council, commissions and committees of the
Association, and the public.

“(a) Composition. It shall be composed of thirty-
six (36) members chosen in the following manner:
“(1) One (1) member from each of the cur-
rently constituted scientific sections of the Cali-
fornia Medical Association — (18).

“(2) Eighteen (18) members-at-large having
as broad a representation as practical from the
various categories of medicine.

“The Council, on recommendation of the Scien-
tific Board and others, shall name the scientific
disciplines to be included in the various categories,
and the organizations or groups which may nom-
inate members-at-large to the Board.

“Each scientific section and each named member-
at-large organization or group, shall present at least
three (3) names in nomination to the Nominating

Committee of the Board. The Nominating Commit-
tee shall recommend two (2) names from each sec-
tion and each member-at-large category to the
Executive Committee of the Board and to the Com-
mittee on Committees of the Council. Election to
membership on the Board shall be made from these
nominees by the Council.

“In addition to the above, two (2) members of
the Council shall be nominated each year to serve
as members of the Scientific Board.

“The editor of California Medicine shall be an
ex-officio, nonvoting member of the Scientific Board.

“(b) Term of Office. The term of office for the
members of the Scientific Board shall be three (3)
years with eligibility for reelection, except that the
initial terms of office, when the Board is created,
shall be for lesser terms to establish the rotation of
one-third (1/3 ) of the Board’s membership each
year.

“The initial Board shall be selected from the
nominations made by the eighteen (18) scientific
sections and the categories and groups named as
members-at-large, by a special committee of the
California Medical Association appointed for this
purpose by the chairman of the Council. One-third
( 1/3 ) of the initial terms of office shall be for one
(1) year; another one-third (%) for the two (2)
years; and a final one-third (%) for three (3)
years. The length of term of each of the initial ap-
pointees shall be determined by lot.

“(c) Meetings of the Scientific Board. The Sci-
entific Board shall meet annually at the time of the
Annual Session of the House of Delegates and the
Scientific Assembly. Other meetings of the Board
may be held on call of the majority of the members
of the Executive Committee of the Board.

“(d) Representation in House of Delegates. The
Scientific Board shall name eighteen (18) of its
members as ex-officio delegates to the House of Dele-
gates to be chosen in the following manner:

“Nine (9) members shall be chosen from the
scientific sections, and nine (9) members shall
be chosen from the members-at-large. Not more
than one ( 1 ) representative shall be chosen from
any scientific discipline listed in the Bylaws as a
scientific section. When there are two (2) or more
members on the Scientific Board from the same
discipline, the senior member in term of service
on the Board shall serve as the member of the
House of Delegates representing that discipline
from the Board. When the terms of service of two
(2) or more are equal, then the one to serve
representing that discipline shall be determined
by lot. The initial membership in the House of
Delegates from the Scientific Board shall be de-

116

CALIFORNIA MEDICINE

termined by a special committee appointed for
this purpose by the chairman of the Council.
“The Bylaw provision concerning notification to
the secretary of the Association of the names and
addresses of delegates shall be followed.

“Section 2 — Committees of the Scientific Board

“(a) Executive Committee. The Executive Com-
mittee shall consist of seven (7) members from the
Scientific Board including the chairmen of the com-
mittees on Continuing Medical Education and on
Scientific Assemblies, (but no more than two (2)
members from any one discipline), two (2) mem-
bers from the Council designated annually by the
Council, and the editor of California Medicine
as an ex-officio member without the right to vote.

“This shall be a working committee carrying out
the usual functions of an Executive Committee,
which shall meet on call of the chairman, any three
(3) members of the committee, chairman of the
Council or the president of the Association.

“(b) The Committee on Continuing Medical Edu-
cation. The Committee on Continuing Medical
Education shall consist of five (5) members from
the Scientific Board including the chairman of the
Committee on Scientific Assemblies. No more than
one (1) member from any discipline shall be ap-
pointed. The directors of Continuing Medical Edu-
cation of the medical schools in California shall be
invited to sit as consulting members, (nonvoting),
of this committee.

“The functions of this committee shall be:

“(1) Responsibility for all activities of contin-
uing medical education, postgraduate courses,
coordination of educational activities with medi-
cal schools, other societies, organizations and
industries.

“(2) To study and implement recommendations
made by the Committee on Scientific Assemblies.

“(3) To study and recommend programs for
education and continuing education of those in
allied health professions and services.

“(c) Committee on Scientific Assemblies. The
Committee on Scientific Assemblies shall consist of
nine (9) members from the Scientific Board, one
(1) of whom shall be chairman of the Committee on
Continuing Medical Education.

The functions of this committee shall be:

“(1) The long-term planning and implemen-
tation of scientific meetings.

“(2) To determine the character and scope of
the scientific proceedings of the Association for
each Annual Session, and to invite the guest
speakers, subject to the instructions of the
Council.

“(3) It shall act as the Committee on Arrange-
ments for the Annual Session and have charge of
all local arrangements not otherwise provided for.
It shall have power to appoint local advisory
members and subcommittees to aid in its work.

“(4) To have at least one joint session with
the section secretaries, at a time and place to be
designated by the chairman of the committee, at
least forty-five (45) days prior to the Annual
Session, to coordinate more efficiently the various
activities of the Association at its Annual Session.

“(5) To ensure that if a postgraduate course
is to be given at the time of the Annual Session,
it shall be given with the approval of the Com-
mittee on Continuing Medical Education and the
Committee on Scientific Assemblies, and be in-
tegrated with the program of the Scientific As-
sembly.

“(6) At least thirty (30) days prior to each
Annual Session, to prepare and issue a program
announcing the order in which papers and dis-
cussions shall be presented.

“(d) Committee on Scientific Information. The
Committee on Scientific Information shall consist of
five (5) members from the Scientific Board.

“It shall serve as a source for obtaining and dis-
seminating scientific information to members of the
Association, the House of Delegates, the Council,
commissions and committees, and the public.

“(e) Committee on California Medicine. The
Committee on California Medicine shall consist of
five (5) members from the Scientific Board.

“It shall serve in an advisory capacity to the edi-
tor and Editorial Board of California Medicine.

“(f) Committee on Cancer. The Committee on
Cancer shall consist of seven (7) members; at least
three (3) of whom shall be members of the Scien-
tific Board, and the remainder of whom shall be
selected from the membership-at-large of the Asso-
ciation. The Committee on Cancer shall be respon-
sible for the activities of this Association in the
field of cancer research, prevention, education and
control, through which the following standing sub-
committees shall report:

“(1) Committee on Cancer Education.

“(2) Committee on Tumor Tissue Registry.

“(3) Committee on Consultative Tumor Boards.

“(4) Committee on New and Unproved Meth-
ods of Cancer Treatment.

“Each of these subcommittees shall be composed
of five (5) members. The chairman shall be selected
from the Committee on Cancer, and four (4) addi-
tional members shall be selected from the member-
ship-at-large of the Association.

“(g) Committee on Maternal and Child Care.
The Committee on Maternal and Child Care shall

VOL. 97, NO. 2 • AUGUST 1962

117

consist of nine (9) members, two (2) of whom
shall be members of the Scientific Board represent-
ing Obstetrics and Gynecology, and Pediatrics, and
seven (7) of whom shall be selected from the mem-
bership-at-large of the Association.

“(h) Committee on Nominations. The Commit-
tee on Nominations shall consist of three (3) mem-
bers elected by the Scientific Board at the annual
meeting of the Board to serve for one (1) year,
eligible for reelection but once, and thereafter only
after a one (1) year interval. The chairman of the
Scientific Board shall nominate three (3) members
and the Board-at-large shall nominate at least three
(3) members for election to this committee.

“The functions of this committee shall be to re-
ceive and consider nominations for:

“(1) Membership on the Scientific Board from
the various scientific sections and scientific or-
ganizations eligible to nominate members-at-large
of the Scientific Board.

“(2) Membership on the committees of the
Board.

“(3) Chairmen, vice-chairmen and secretaries
of committees and subcommittees of the Board.
“The Nominating Committee, after consulting
with the Executive Committee of the Board, shall
recommend to the Committee on Committees of the
Council two (2) nominations for each vacancy. The
Council shall elect from these nominees, members
to the Board and to the committees and subcom-
mittees of the Board.

“Section 3 — General Provisions Governing the Scientific
Board, Its Committees and Subcommittees

“Except as specifically provided herein, the term
of office for a member of the Board, a committee or
subcommittee, shall be three (3) years, provided,
however, that members of the Scientific Board shall
not be appointed to a term on a committee for a
length of time exceeding their term as a member of
the Board.

“Members of the Board shall not serve simultane-
ously on more than three (3) committees of the
Board.

“The provisions relating to procedures and an-
nual reports applicable to California Medical
Association commissions and committees shall be
applicable to the Scientific Board, its committees
and subcommittees, unless otherwise specifically
provided for.

“Section 4 — Scientific Sections
“(a) The Association shall be divided into eigh-
teen (18) scientific sections as follows: Internal
Medicine; General Surgery; Pediatrics; Ear, Nose
and Throat; Urology, Anesthesiology; Obstetrics
and Gynecology; Radiology; Industrial Medicine

and Surgery; Pathology and Bacteriology; Derma-
tology and Syphilology; Psychiatry and Neu-
rology; General Practice; Preventive Medicine and
Public Health; Allergy; Eye; Orthopedics; and
Physical Medicine.

“(b) Rules of Procedure of Scientific Sections.
Each scientific section shall adopt rules of procedure
for its own better government and work. Its officers
shall be responsible for the proper keeping of
records of scientific and business meetings.

“(c) Officers of Sections. The members of each
section shall, at the regular Annual Session of the
Association, elect a chairman and a secretary to
serve for the term of one year.

“(d) Nominations to the Scientific Board. Each
scientific section shall be represented on the Scien-
tific Board by one (1) member who shall serve for
a three-year term. Three (3) nominations shall be
made for this appointment to the Nominating Com-
mittee of the Scientific Board. These nominations
shall be made at the time of the Annual Session of
the Association.

“(e) Program. Each of the sections may present
a scientific program at the Annual Session of the
Association, and its officers shall be responsible for
the proper preparation of the same, and for the
proper cooperation with other scientific sections or
organizations in presenting a scientific program
during the annual meeting.

“Section 5 — Meetings and Registration at Annual Session

“The general meetings of the Association, the
meetings of the House of Delegates, and the meet-
ings of the Scientific Assembly and its sections at
any session shall be held in the State of California
at the same locality and in buildings as convenient
of access, one to the other, as may be possible.

“Each member in attendance at any session shall
register, after his right to membership has been
verified by reference to the records of this Asso-
ciation. No member shall take part in any of the
proceedings of any session until he has complied
with the provisions of this section of the Bylaws.

“Section 6 — Addresses and Scientific Papers at
Annual Session

“The program at Annual Sessions shall be divided
between general meetings and section meetings as
the Council shall deem appropriate.

“At the general meetings, the president may de-
liver an address, and, with the sanction of the
Council, other addresses and reports may be pre-
sented.

“Excepting the president’s address and such other
addresses and reports as the Council may determine,
no address or paper shall occupy more than twenty
minutes in delivery.

118

CALIFORNIA MEDICINE

“No member, except by unanimous consent, shall
speak more than once in the discussion of any paper
nor longer than five minutes at any one time. This
subsection of the Bylaws shall be printed on all
programs of general and section meetings.

“All papers read before this Association shall be
its property. Each paper, when it has been read,
shall be deposited with the secretary of the section,
by him to be promptly turned over to the secretary
of the Association.

“Authors of papers read before this Association
shall not cause them to be published elsewhere except
with the consent of the Editorial Board.”

ACTION : Adopted by House.

BYLAW AMENDMENT No. 14

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Chapter II, Section 3(b) of the

Bylaws of the California Medical Association shall
be amended by inserting after the second sentence
of said Section 3(b) a new sentence to read as
follows:

“A person holding a physician’s and surgeon’s cer-
tificate under the jurisdiction of the State Board of
Osteopathic Examiners on or before September 30.
1962, who holds a degree of Doctor of Medicine
issued to him by the College of Osteopathic Physi-
cians and Surgeons (or its successor), and whose
license to practice medicine and surgery is unre-
voked and unsuspended, is eligible for election to
active membership in a component society. How-
ever, in the event that a charter is outstanding to a
statewide component society, none of such persons
shall be permitted to join any component society
other than the statewide component society, without
the express consent of such statewide society.”

ACTION : Adopted by House.

BYLAW AMENDMENTS FOR ACTION IN 1963

BYLAW AMENDMENT No. 12

Author: Los Angeles delegation.

Whereas, the Council of the C.M.A. is an im-
portant group in carrying on the activities of the
C.M.A. ; and

Whereas, it is important that the members of the
Council be responsible to the desires of the majority
of the members of the C.M.A. ; and

Whereas, a democratic organization provides a
vote to all its members; now, therefore, be it

Resolved: That the Bylaws of the C.M.A., Chap-
ter VIII. Section 6 and Section 6.5 be amended to
read as follows:

“Section 6 — Election of District Councilors in Districts
Having One or More Councilors

“The members of each component society shall
elect the number of District Councilors to which
the component society is entitled. At least sixty (60)
days prior to the next scheduled session of the
House of Delegates, the Secretary of each compon-
ent society shall forward to the Secretary of the
Association, on forms provided by the Association,
the names and addresses of those District Coun-
cilors, so elected, and shall certify thereon, the term
of service of each individual Councilor.

“District Councilors shall be elected, by the dis-
tricts, at the same time and manner that Delegates
and Alternates to the House of Delegates of the
Association are elected by their respective com-
ponent societies.

“Districts, in which Councilor vacancies are about
to occur, shall, by secret ballot and majority vote,
of the members of the district eligible to vote, and
voting, elect a District Councilor to fill each vacancy,
from such district, to serve for the ensuing term.

“Where new offices are created under the terms
of Article III, Part B, Section 9(a) of the Consti-
tution, each such new office shall be numbered seri-
ally with those already existing, and shall carry an
initial term extending to the same date as has been
previously established for offices in the same nu-
merical sequence, heretofore established, and there-
after for a term of three (3) years.”
and be it further

Resolved: That Section 6.5 of Chapter VIII of
the Bylaws of the C.M.A. be repealed and stricken
from the Bylaws.

ACTION: Bylaw Amendment No. 12 (together with
Constitutional Amendment No. 4 printed under 1962
Constitutional Amendments ) was referred to a special
ad hoc committee to be appointed by the Speaker
with instructions to study the proposals and make a
report to the House of Delegates at its next annual
session.

BYLAW AMENDMENT No. 13

Author: Allyn J. McDowell.

Representing: Los Angeles.

Whereas, the C.M.A. Bylaws have heretofore
provided for a referendum vote of all the members

VOL. 97, NO. 2 • AUGUST 1962

119

only at the discretion of either the Council or the
House of Delegates ; and

Whereas, these two referring bodies constitute
the very bodies concerning whose decisions any
appeal of the members might be needed or sought;
and

Whereas, it is inconsistent with democratic prin-
ciples that members of this Association should thus
in effect have no right of appeal concerning actions
of the Council or House of Delegates; now, there-
fore, be it

Resolved: That Chapter XII, Section 1 be
amended by adding the following :

Association within sixty days after the action is
taken and if the petition is signed by a number of
active members amounting to more than twice the
number of voting delegates at the prior meeting of
the House of Delegates. This number of petitioners
shall constitute a referring body”; and be it further

Resolved: That Chapter XII, Section 2 be
amended by adding the following:

“Whenever a referendum vote is initiated through
a petition of appeal the petition shall name an active
member as the initiator and that member shall have
the privilege of selecting or composing a written
argument of 1,000 words or less to be presented with
the ballot on behalf of the petitioners.”

ACTION: Referred to a special ad hoc committee
to be appointed by the Speaker with instructions to
study the proposals and make a report to the House
of Delegates at its next Annual Session.

120

CALIFORNIA MEDICINE

CALIFORNIA MEDICAL ASSOCIATION
1963 annual meeting
Ambassador Hotel, Los Angeles, March 24-27, 1963

announcing: first call for scientific exhibits,

MEDICAL MOTION PICTURES, SCIENTIFIC PAPERS
THIS IS YOUR MEETING .... PLAN TO PARTICIPATE

Do you have A SCIENTIFIC EXHIBIT? ... A MEDICAL MOTION PICTURE?

. . . Write now to the CMA Committee on Scientific Work, 693 Sutter Street,
San Francisco 2, for application forms for Scientific Exhibits and Medical Motion
Pictures. Don’t wait! Completed application forms must be in this office soon so
that space and time can be allotted.

i i i

do XjOt/l let VO A PAPER you’d like to present to your colleagues? . . .
Write to the appropriate Section Secretary . . . Don’t delay . . . Do it today . . .
Programs are being planned now!

SECRETARIES OF THE

ALLERGY Walter R. MacLaren, M.D.

696 East Colorado Street, Pasadena 1

ANESTHESIOLOGY James S. West, M.D.

Box 8914, Los Angeles 8

DERMATOLOGY AND

SYPHILOLOGY Herbert L. Joseph, M.D.

1516 Napa Street, Vallejo

EAR, NOSE AND THROAT . . William F. Baxter, M.D,
762 Altos Oaks Drive, Los Altos

EYE James F. Kleckner, M.D.

3731 Stocker Street, Los Angeles 8

GENERAL PRACTICE .... Herbert A. Holden, M.D.

383 West Joaquin Avenue, San Leandro

GENERAL SURGERY . . . . . David B. Hinshaw, M.D.

Room 9440, 1200 North State Street,

Los Angeles 33

INDUSTRIAL MEDICINE AND
SURGERY Carl E. Nemethi, M.D.

5592 Santa Fe Avenue, Los Angeles 58

INTERNAL MEDICINE . . Harney M. Cordua, Jr., M.D.

2561 First Avenue, San Diego 3

SCIENTIFIC SECTIONS

OBSTETRICS AND GYNECOLOGY . . Leon P. Fox, M.D.
303 North 15th Street, San Jose 12

ORTHOPEDICS Edwin G. Bovill, Jr., M.D.

450 Sutter Street, San Francisco 8

PATHOLOGY AND

BACTERIOLOGY Richard O. Myers, M.D.

Valley Presbyterian Hospital, 15107 Vanowen Street,

Van Nuys

PEDIATRICS Lawrence E. Reck, M.D.

2950 Sixth Avenue, San Diego 3

PHYSICAL MEDICINE Frances Baker, M.D.

1 Tilton Avenue, San Mateo

PREVENTIVE MEDICINE AND

PUBLIC HEALTH Herbert Bauer, M.D.

Yolo County Health Department, P.O. Box 532, Woodland

PSYCHIATRY AND NEUROLOGY . Henry S. Colony, M.D.
411 30th Street, Oakland 9

RADIOLOGY Walter Gaines, M.D.

120 St. Matthews Avenue, San Mateo

UROLOGY . . . . Henry Bodner, M.D.

4911 Van Nuys Boulevard, Van Nuys

VOL. 97, NO. 2

AUGUST 1962

121

The Industrial “Blank Check"

No PHYSICIAN in his right mind would sign a financial agreement involving thousands
of dollars without a thorough knowledge of its contents and implications. Yet, every
day, California physicians submit industrial accident reports involving vast sums of
money with hardly a second thought.

Standard forms or narrative reports concerning industrial injuries have important,
unique characteristics. They are legal documents as well as medical records. They are
often the sole basis on which large amounts of money are committed or actually paid
in awards, litigation costs and disability payments. They may also have significant
effect on the employment status of the insured worker.

Making initial reports accurate, clear and concise best serves the best interests
of all parties. Anything less may result in confusion and injustice, and is, moreover,
harmful to the reputation of the individual physician and of the profession.

Minimum requirements are:

1. The patient’s statement of how the alleged injury occurred.

2. An accurate diagnosis — if this can be stated with assurance. The use of such
terms as “aggravation” or “recurrence” is helpful in clarifying the relationship
of the injury to pre-existing conditions. When exposure to irradiation or other
harmful agent is alleged, but no immediate verification of exposure is available,
“suspected exposure” should be stated in the report. Any diagnosis that is not
substantiated should be omitted.

3. A precise statement of disability — both subjective and objective — with accu-
rately stated measurements of function. The physician’s own evaluation of the
validity of the apparent disabling factors should be stated when indicated.

4. Realistic estimates of the duration of disability — total or partial. Overly opti-
mistic prognostications cause unnecessary, costly reappraisals and are discourag-
ing to the worker, to the employer and to his insurance carrier. Any anticipated
permanent disability should be stated on each report and estimated with all
possible accuracy.

5. An indication of the need for further treatment and the kind of treatment.

6. Finally — and important — the physician must sign the report himself. The
responsibilities that the physician has to the patient, to the employer and to
himself are too great to be delegated to an aide.

Don’t be guilty of handing out “industrial blank checks.” They can bounce — with
most embarrassing consequences.

Committee on Occupational Health
California Medical Association

Comments and Questions Are Welcomed by the Committee

* This is the tenth of a series of articles prepared by the Committee on Occupational Health.

PUBLIC HEALTH REPORT

MALCOLM H. MERRILL, M.D., M.P.H.

Director, State Department of Public Health

In eight of Lhe ten years between 1950 and 1960,
more cases of measles were reported in California
than of any other communicable disease. During
1961, another relatively high measles year, 39,201
cases and 26 deaths were reported. The case-fatality
ratio continues to be slightly less than one death
for every 1.000 cases. Since measles is greatly un-
der-reported. the true case-fatality rate is probably
closer to one in 10,000.

Thirteen of these fatal cases were in children
three years of age or under; 22 of the 26 were
under 10 years of age and only four were over 10.
It is interesting to note that in nine of 13 fatal cases
complicated by pneumonia alone the patients were
under five years of age. The reverse was true where
encephalitis was the complication, nine of 13 were
over the age of five years.

The prospect of effective live virus vaccine becom-
ing generally available sometime in the near future
gives hope that this important cause of sickness and
death can soon be greatly reduced and eventually
eliminated as a public health problem.

1 i i

For almost five years, the California Medical
Association and the State Health Department have
been jointly studying all deaths of women that
occur during or within 90 days of termination of
pregnancy. Within this period, there have been 725
deaths meeting this definition, with review com-
pleted on 515 of them.

Of the maternal deaths studied to date, there have
been over one hundred considered due to abortion.
In at least 70 per cent of these cases the abortion
was criminally induced. An additional number of
the deaths are suspect but cannot unequivocally be
assigned as a criminally induced abortion. Less than
15 per cent of the abortions were spontaneous. A
few deaths were a result of attempted abortion in

cases in which a woman mistakenly believed she
was pregnant. These cases were not included in the
study.

A preliminary investigation of the information
collected on the abortion deaths studied to date
revealed that almost two-thirds of the women were
married, 15 per cent were never married and the
remainder were widowed, divorced, separated or
were of unknown marital status.

Less than 15 per cent of the women had never
before been pregnant, while almost 30 per cent had
had five or more pregnancies. Almost half of the
women dying from abortion were 30 years of age
or older. A detailed report on maternal deaths re-
sulting from abortion is being prepared for later
publication. Earlier findings of the maternal mor-
tality study were published in the November, 1960,
issue of California Medicine.

i 1 1

An unusual death occurred in Southern California
when wild tobacco leaves were mistaken for collard
greens. The plants were picked in the yard of a
vacant house, washed, boiled with strips of bacon
and served for supper to a family of four.

One hour afterward all four became dizzy and
nauseated, vomited, and had difficulty swallowing,
talking and seeing. Two of the four were ill enough
to be hospitalized and one of them, a seven year
old child, died within 12 hours. Symptoms lasted
about 24 hours in those who recovered.

The offending plant was identified as wild tobacco,
native to Argentina and brought to California by
the Spanish padres. Its first leaves are cabbage-like
with a greyish color. Hence the likelihood of con-
fusing it with collard greens. In its mature form it
has been mistaken for pokeweed, a wild plant some-
times cooked and eaten by persons in southern
states.

VOL. 97. NO. 2 • AUGUST 1962

123

LETTERS to the Editor

California Physicians' Service

You recently devoted the major portion of a large
issue* to California Physicians’ Service-Blue Shield.
On behalf of the 20 or 25 per cent of our C.M.A.
members who do not belong to C.P.S. may I ask
your publication of this article on an equal or pro-
portionate space basis.

C.P.S.— THE DOCTORS' PLAN

1. Purpose: C.P.S. was founded in 1939 to de-
velop a method to distribute the cost of sickness
service on a voluntary basis and “without injury
to the standards of medical practice.” Physicians
were to be reimbursed on a unit basis, and it was
hoped that the unit might amount to perhaps 80
per cent of the modest fee schedule then agreed
upon. It was soon found that funds available would
only pay at about 50 per cent on the unit. Revision
of the program was accordingly made, and the
House of Delegates repeatedly stressed the desirabil-
ity of indemnity, rather than service-type coverage,
at least for those above the lower income levels.

2. Beneficiary Mem bership : The beneficiary mem-
bership grew and today reportedly amounts to about
one million persons. In addition, C.P.S. arranges the
distribution of certain services for persons eligible
for medical coverage under the Medicare and Pub-
lic Assistance Medical Care programs. In one recent
year its volume of business exceeded 57 million
dollars.

3. Professional Membership : A majority of the
physicians in the California Medical Association are
reportedly professional members (about 80 per
cent). However, it is noteworthy that in the two
larger conurbations (San Francisco and Los An-
geles) the professional membership is only a little
over 70 per cent.

Further, the presidents of the three largest medi-
cal societies in the state, the San Francisco Medical
Society, the Alameda-Contra Costa Medical Society
and the Los Angeles Medical Society are not mem-
bers. The chairman of the C.M.A. TV-Radio Com-
mittee is not a member. These persons vote in the
House of Delegates of the C.M.A., which group
doubles as the guiding body of C.P.S. As a result.

* California Medicine, 94:156-172, March 1962.

124

we have distinguished physicians debating and vot-
ing on issues without themselves being involved
directly. This conjures “Do as I tell you, don’t do
as I do.”

4. Performance: For beneficiary members, C.P.S.
has in general provided very good service — excel-
lent surgical benefits, fair medical benefits and good
hospital benefits — all with little or no added charge
on the part of the patient (except in the higher
income brackets). In accepting what are essentially
substandard fees for many medical procedures, the
profession is of course subsidizing C.P.S. to a very
significant degree.

For physicians working in group practice, or in
branches of medicine that permit large volume,
“production-line” methods, the current C.P.S. allow-
ances are often regarded as acceptable. However,
for physicians in the nonsurgical branches of medi-
cine (internists, pediatricians, nonsurgical general-
ists, radiologists) and others in solo practice, many
allowances are so small that if a large majority of
their patients were to be compensated for at C.P.S.
rates, they would not be able to pay their office
nurses and office rent. Since the public needs and
deserves wide availability of private medical serv-
ice, it would be desirable that medical (as opposed
to surgical) allowances under C.P.S. were revised.

It is said that only about 7 per cent of our pa-
tients are currently covered by C.P.S. Even if only
1 per cent were so covered, and covered in a manner
that set a bad precedent for good quality of medical
care, it would be evil because, as the Doctors’ Plan,
C.P.S. is held a potential model for other insurance
programs. Worse, it may be held as a model for
eventual state or federal medical service. For this
reason, it is doubly important that necessary cor-
rections be made.

5. Abuses: C.P.S. pays grossly unequal fees for
identical diagnostic procedures depending on
whether they are performed in a hospital building or
a medical building. It is estimated that hundreds of
thousands of dollars are paid to hospital radiolo-
gists each year in excess of payments for identical
procedures performed by well-qualified radiologists
in medical office buildings.

C.P.S. pays and has paid literally millions of dol-
lars for medical services not rendered. The radi-
ology portion of the C.P.S. schedule allows for (a)

CALIFORNIA MEDICINE

expert examination by referral plus (b) independent
consultation report. However, a majority of non-
hospital radiology is reportedly performed by non-
radiologists, yet C.P.S. has paid and still pays the
full fee, even though no independent consultation is
provided. These two wasteful procedures have been
drawn repeatedly to the attention of the C.P.S.
Trustees for some 21 years, without being corrected.

When pressed, C.P.S. officials state that they can-
not make the necessary changes, that the C.M.A. or
one of its committees “must instruct it first. Well.
C.P.S. makes frequent changes in contracts and
benefits without specific House instruction. It could
effect the necessary reforms by administrative ac-
tion. It is doubtful if such action will ever be ini-
tiated by Trustees or Delegates since so many are
recipients of largesse in the form of specialist radi-
ology fees for non-specialist type radiology. This
fact is unknown to some and ignored by others.
The public is the loser. After all, there is no question
as to the difference in quality and quantity between
a G.I. Series performed by an experienced radiolo-
gist in a well-equipped office and one performed by
a nonradiologist with “a cup of barium and a
fluoroscope.” Yet C.P.S. pays the same fee for either
procedure! When the average G.P. himself needs
a G.I. Series, where does he go? To the radiologist,
as far as we can ascertain. And more power to him.

Correction of the abuses should result in avail-
ability of added medical funds. These could well be
allocated to currently low portions of the schedule
(such as medical office visits, internist and pediatric
procedures) .

6. Comments: Should the medical profession be
in the insurance business? Should the profession,
which believes in free enterprise, accept the shelter
of a tax-free status such as C.P.S. possesses? Fi-
nally, should we compete with private enterprise
(voluntary health insurance companies) by means
of hidden subsidies, which some of the low medical
fees of C.P.S. amount to?

A special committee of the Council of the C.M.A.
studied this matter during 1961-62 and recom-
mended as follows to the Council:

1. For income ceilings under .$4200, a service
plan with a relative value factor of 4.

2. For those under $6000, a service plan with a
relative value factor of 5.

3. For those above $6000 an indemnity, or major
medical, or usual fee program.

The Chairman of the Committee reported its
opinion that C.P.S. cannot and should not compete
with closed panel plans.

Summary: It seems that there are two main is-
sues:

a. How can we maintain a good quality of medi-
cal care at reasonable fees for a majority of the
public?

b. Who is going to control the economics of
medical care?

The answers include:

a. Good quality of medical care will be encour-
aged by aiding competent individual medical as well
as surgical practitioners to survive. This means
recognizing quality as well as quantity.

b. The economics of medical care can best be
controlled by joint efforts of experts in the two
fields: Good private insurance companies and con-
scientious physicians. I submit that the public will
be better served if we, the doctors, stick primarily
to the practice of our profession and encourage
insurance companies to develop programs for those
above the lower income ceiling levels. We may need
to subsidize the low-income policies even more than
we do now, but in the end we will be setting a safer
precedent for general population “health insurance”
coverage (which probably should involve coinsur-
ance or reasonable deductible features).

Yours sincerely,

L. H. Garland, M.D.

VOL. 97, NO. 2

• AUGUST 1962

125

- 3n jfflemonam

Bloomfield, Arthur L., San Francisco. Died July 5,
1962, in San Francisco, aged 74, of heart disease. Graduate
of Johns Hopkins University School of Medicine, Baltimore,
Maryland, 1911. Licensed in California in 1926. Doctor
Bloomfield was a member of the San Francisco Medical
Society.

Booke, S. Gerald, Monrovia. Died June 28, 1962, in
Monrovia, aged 61, of chronic congestive heart failure.
Graduate of the University of Buffalo School of Medicine,
New York, 1924. Licensed in California in 1925. Doctor
Booke was a member of the Los Angeles County Medical
Association.

Brosemer, Lowell R., Sacramento. Died June 26, 1962,
in San Francisco, aged 41. Graduate of the University of
Maryland School of Medicine and College of Physicians
and Surgeons, Baltimore, 1946. Licensed in California in
1947. Doctor Brosemer was a member of the Sacramento
Society for Medical Improvement.

Campbell, Walter Mac, Sacramento. Died June 15, 1962,
in Sacramento, aged 57, of heart disease. Graduate of the
College of Medical Evangelists, Loma Linda-Los Angeles,
1934. Licensed in California in 1934. Doctor Campbell was
a member of the Sacramento Society for Medical Improve-
ment.

Huff, Lucius Johnson, Berkeley. Died February 9, 1962,
in Berkeley, aged 89, of cerebral hemorrhage. Graduate of
the University of Southern California School of Medicine,
Los Angeles, 1905. Licensed in California in 1905. Doctor
Huff was a member of the Los Angeles County Medical
Association, a life member of the California Medical Asso-
ciation, and a member of the American Medical Association.

Jones, Newell, Encino. Died June 18, 1962, in Encino,
aged 80. Graduate of Illinois Medical College, Chicago,
1905. Licensed in California in 1923. Doctor Jones was a
member of the Los Angeles County Medical Association.

Kohn, Frank, Tulare. Died June 18, 1962, in Tulare,
aged 70. Graduate of the University of Nebraska College of
Medicine, Omaha, 1923. Licensed in California in 1926.
Doctor Kohn was a retired member of the Tulare County
Medical Society and the California Medical Association, and
an associate member of the American Medical Association.

Stabel, John Alois, Sacramento. Died June 14, 1962, in
Sacramento, aged 64. Graduate of the Universitat Heidelberg
Medizinische Fakultat, Baden, Germany, 1922. Licensed
in California in 1926. Doctor Stabel was a member of the
Sacramento Society for Medical Improvement.

126

CALIFORNIA MEDICINE

Membership and Organization

Membership is the foundation of an organization.
The structure of objectives and program resting
upon it must be built by interested and enthusiastic
workers. The President of the Woman’s Auxiliary
to the California Medical Association, Mrs. Floyd
K. Anderson, has given us the following motto for
the year 1962-63:

“ Increase Membership
Strengthen Friendship
And let it begin with me.”

Probably at no time in our history as an Auxiliary
has it been more important that we endeavor to
achieve such a goal. We recognize the fact that we
are an Auxiliary and. therefore, the challenges and
problems which face the Medical Association are
also our challenges and our problems and that we
must strive to assist in their solution. In order to
grow in strength and influence we need to grow in
numbers. We need every physician’s wife as a
member of the Auxiliary. And we believe that every
physician’s wife needs her membership in the
Auxiliary.

Our potential for growth in membership in California is
a real challenge. At the close of the year 1961-1962 we had
7,383 members in the state, an increase of 113 over the pre-
vious year. We are the largest State Auxiliary in the coun-
try. We also like to think we are the best. But there are
over 17,000 doctors in the California Medical Association.
Where are the nearly 10,000 Missing Wives! Most of them
live in areas in which there are organized County Auxili-
aries. We have 34 County Auxiliaries, ranging in size from
Los Angeles County with a membership of over 1,500 to
Tehama with 9 members. Every doctor who is a member of
the California Medical Association should urge his wife to
join the Auxiliary if she does not belong. These missing
wives are missing an opportunity! Among all of the organi-
zations to which she may belong, the Woman’s Auxiliary is
unique. Our basis for membership is the fact that we are
all wives of doctors. So we begin with the mutual interest
we all share in helping our husbands and their chosen pro-
fession. Where else can you find so strong a reason for
working together?

Included in our total of 7,383 members are 37 members-
at-large who live in counties where there is no organized
County Auxiliary. We are proud of these 37 women. Al-
though they do not have the advantage of enjoying the fel-

lowship and programs of a group meeting, they continue to
support the policies and programs of the State Auxiliary by
payment of their dues. And we feel sure that they do their
part as liaison between the public and the medical profes-
sion in the areas in which they live.

Through County Auxiliary programs the physician’s wife
is provided with accurate information on matters concerning
medicine and public health. She will be able to answer the
questions of her neighbors and friends. Possession of the
correct information is her responsibility, for she is more
often quoted as a physician’s wife than as an individual.
Through the Auxiliary she is able to learn about the health
needs of her community and what can be done about them,
which makes her participation in other community organi-
zations more effective. Whether or not she chooses the role,
she represents the medical profession to the public with
whom she associates. She can wield a positive influence if
she is well informed and articulate. She can well consider
the fact that in helping the public to better understand the
aims and problems of her husband’s profession she is also
helping herself, since it is her way of life as well as his.

It is a privilege to belong to a County Auxiliary.
It is also a pleasure, for one of membership’s richest
rewards is the opportunity to be friends with the
wives and families of other physicians. Friendships
can be strengthened through working together.

During the summer the membership committees
in the County Auxiliaries will be making plans for
maintaining the active interest of their present mem-
bers, for creating a desire to rejoin on the part
of members who have dropped out and for increas-
ing their membership by inviting all wives who are
eligible to become members. Experience has taught
us that the personal invitation to “come with me
to the next Auxiliary meeting” has the strongest
appeal to the prospective member. So we hope
that every member will consider herself a part of
her Auxiliary’s membership committee in this sense
and that she will invite someone she knows and
thinks should belong. “Let it begin with me.”

To the members of the California Medical Asso-
ciation :

“Let it begin with YOU.”

Invite your wife to join.

Mrs. John L. Gallagher,

Membership Chairman
Womans Auxiliary to the
California Medical Association

VOL. 97, NO. 2

AUGUST 1962

127

INFORMATION

The Inability of the Consumer Price
Index to Measure "Cost of Quality"
Of Medical Care

A Report of the Bureau of Research and

Planning, California Medical Association

The problem of assigning values to the cost of
living in the United States is of central importance
to our economy. This problem has been attacked in
various ways depending upon the use of the data
and their analysis. Although the central problem —
measurement of the cost of living — is still unre-
solved, much has been accomplished through the
use of the Consumer Price Index of the Bureau of
Labor Statistics in measuring the movement of
prices relative to personal income in the economy.
This device is of considerable importance in an-
alyzing and understanding the price of medical care
and. in particular, movements in its price.

At present all data collected for the measurement
of price changes within the area of medical care
are presented by the Bureau of Labor Statistics in
the Medical Care Index component of the Con-
sumer Price Index. It represents just one part of
the Consumer Price Index and contains within it
the Physician Fee Index.

Generally, over short periods the Index does a
more than adequate job in portraying price changes
for the components. However, over longer periods
the Index is faced with a number of problems
which tend to give it an upward bias. The causes
for this bias are based upon changes in the quality
of the goods or services and the replacement of one
good or service by another. This problem has not
been ignored by the Bureau of Labor Statistics;
an effort has been made to filter out changes that
reflect more than changes in price. Two techniques
employed are those of “linking” and “factoring.”

The first of these techniques, “linking,” tries
to take into account the effect of a quality change
by cancelling out the difference in price between
the commodity (good) with and without the quality
change. This technique, the most frequently used
for quality changes, assumes that the full difference
in price between the goods of different quality is
reflected only in the price increase. The second

The Consumer Price Index (CPI) of the Bureau
of Labor Statistics is an index which measures the
price changes of 300 goods and services. Among
these 300 items are several which reflect price
changes for selected health care and medical care
services. These comprise the medical care index
and physician fee index, depending on what serv-
ices are being measured.

The Physician Fee Index is based upon charges
for five procedures rendered by physicians: Ap-
pendectomy, tonsillectomy, obstetrical delivery,
home visits and office visits.

Although the CPI takes into account quality
changes in the prices for various goods, it is unable
to do so for services, particularly physicians’
services.

The difficulty in measuring the “cost” of quality
of medical care overstates price increases in the
physician fee and medical care indexes.

method, “factoring,” makes an adjustment for
quality difference by increasing or reducing the
price of the commodity in the current period by
the value of the quality difference, and then com-
paring this adjusted price with the price for the
preceding period. This technique takes into con-
sideration both quality and price change in order
to maintain a continuity of price change within
the index. Although these methods of allowing for
“quality changes” are somewhat effective for dur-
able goods, i.e., automobiles, stoves, furniture and
other types of household appliances, they cannot be
applied to the large number of service items meas-
ured by the C.P.I.

One part of the C.P.I. where the measurement
of quality is of utmost importance is the structure
of the Medical Care Index. The Medical Care Index
measures changes in the cost of hospitalization
(daily service changes), physicians’ fees, health
insurance, medication, dentists’ fees, eye examina-
tions and glasses. The problem of quality measure-
ment is to be found in almost all of the items in
the Medical Care Index. In dealing with quality
change measurement, an example is found in
evaluating hospitalization costs: Although the cost
of daily hospitalization has increased, the length of
hospital stay has decreased. The change in the
Medical Care Index, therefore, does not reflect the
impact of the lessened hospital stay upon the cost
of hospitalization. Fees for physicians’ services, ac-
cording to the C.P.I., have increased greatly in
price. Once again, the increase in price does not
accurately reflect a number of other conditions en-
tering into the pricing of these services, such as
new techniques in the treatment of disease or in-
jury, or length of treatment. Unfortunately, the
Medical Care and the Physician Fee Index fail to
price out these quality changes. The result is an
upward bias in Medical Care prices.

128

CALIFORNIA MEDICINE

[ n the case of a new good,

is priced and given an index value of 100 at the
time it is entered into the schema of the index.
Thereafter it is priced as are other goods, with
changes in price reflected by changes in the index
number. However, whether people are belter off
because of the use of the drug is not reported by
the index, since it is not the function of the index.
After a new product has been introduced, only the
change in cost to, and not the well-being of, the
user is measured. Considering the various manipu-
lative techniques employed to adjust for quality,
it can readily be observed that the C.P.I. does not
accurately measure the effect of the introduction
of a new good or service. As a matter of fact, the
C.P.I. is designed so that the addition, subtraction
or change in quality of goods or services will have
little or no effect upon the measurement of price
changes by the index. Nevertheless, it is apparent
that the introduction of new goods and services
and changes in quality do influence the well-being
of the consumer. In examining the last point, rela-
tive to the apparent increase in prices of medical
care, one authority has concluded that:*

■Richard Ruggles, Measuring the Cost of Quality, Challenge, Vol.
X, No. 2, November 1961.

In the case of medical care, . . . the apparent 30 per cent
increase of the last eight years must he qualified hy con-
sidering the increase in medical knowledge, better drugs
and the new preventive medicines. Certainly the Salk
vaccine was a tremendous medical advance which, in addi-
tion to sparing many lives, will consume dollars that would
have gone for the treatment of polio.

Basically, then, the measurement of price changes comes
down to a question of whether one gets more or less for
his money. In the field of medical care it can be argued that
most people would rather pay today’s prices for today’s
medical care, than yesterday's prices for yesterday’s medical
care. The fact that diseases were treated more cheaply in
yesterday’s world is more than offset hy the increased
knowledge and new drugs available for curing diseases
today. Although it is difficult to measure improvement in
the quality of medicine in quantitative terms, there is no
justification for ignoring it — which is what our present
method of computing price indexes does.

Although the C.P.I. is often criticized for these
shortcomings, it still is a basic source of significant
data which are not available elsewhere. It is a
fact, however, that the Consumer Price Index,
Medical Care Index or Physician Fee Index do not
take into account quality changes and, therefore,
result in the apparent inflation of the prices of
medical care.

California Medical Association, 693 Sutter Street, San Francisco 2.

c--r

VOL. 97, NO. 2

AUGUST 1962

129

NEWS & NOTES

NATIONAL • STATE • COUNTY

ALAMEDA

The new $900,000 William H. and Helen C. Ford Diag-
nostic and Treatment Center at Children’s Hospital of
the East Bay, Oakland, will be dedicated September 23.

With a total of 29,360 square feet, the Diagnostic and
Treatment Center will house the hospital’s outpatient de-
partment (28 specialty clinics), clinical diagnostic labora-
tories, x-ray rooms, and facilities for electroencephalograms
and electrocardiograms.

LOS ANGELES

Dr. Joseph P. O’Connor of Pasadena has been ap-
pointed medical director of the Bureau of Public Assistance
of the Department of Charities of Los Angeles County.

The bureau is responsible for administering the Califor-
nia Medical Care Program under the general supervision
of the State Department of Social Welfare.

Dr. O’Connor’s appointment fills the position left vacant
by the death of Dr. Morris L. Steckel in December, 1961.

Dr. Hans von Leden, associate professor of surgery
(head and neck) at the U.C.L.A. School of Medicine, was
presented with the Casselberry award at the 83rd Annual
Meeting of the American Laryngological Association in
Dallas.

The award is given in recognition for contributions to
the “art and science of laryngology and rhinology.” Dr. von
Leden received it for his investigation of the mechanism of
phonation. The Casselberry award has been presented only
12 times since it was established 50 years ago. Dr. von Leden
is the first recipient since 1949.

❖ ❖ *

The Childrens Hospital of Los Angeles will hold the First
Clinical Conference in Pediatric Anesthesiology on Janu-
ary 26 and 27, 1963. The two-day program will be devoted
to the practical aspects of the preanesthetic, anesthetic, and
postanesthetic management of infants and children. Modern
equipment and monitors will be demonstrated in a model
operating room.

Further information can be obtained by writing to Dr.
M. Digby Leigh, Children’s Hospital of Los Angeles, 4614
Sunset Boulevard, Los Angeles 27.

Dr. David B. Hinshaw has been appointed dean of
Loma Linda University’s School of Medicine, succeeding
Dr. Walter E. Macpherson, who was made vice-president
for medical affairs at the University.

Dr. Hinshaw, a graduate of Loma Linda, has been on the
faculty of the medical school since 1954, becoming professor
of surgery and chairman of the school's department of sur-
gery in 1961.

An introductory course in Expanded Surgery of the
Nasal Septum and Closely Related Structures will be pre-
sented at the Loma Linda University School of Medicine,
Los Angeles, October 29 to November 1.

The program will be under the sponsorship of the depart-
ment of otolaryngology, of which Dr. Leland R. House is

professor and head, and with the cooperation of the Ameri-
ican Rhinologic Society. Dr. Maurice H. Cottle, professor of
otorhinolaryngology, Chicago Medical School, will be the
guest director. In a series of lectures he will present the
history, objectives, embryology and various steps of septum
surgery.

SAN FRANCISCO

The Sixth Annual Western Industrial Health Confer-
ence will be held at the Jack Tar Hotel, San Francisco,
October 12 and 13. The conference brings together the West-
ern Industrial Medical Association, Western Industrial
Nurses Association, American Industrial Hygiene Associa-
tion, American Society of Safety Engineers, and American
Conference of Governmental Industrial Hygienists.

* * *

Dr. D. W. Winnicott of London will be the main speaker
and will participate in a one-day workshop on Providing
for the Child in Health and Crisis which is to be held
Sunday, October 7, at the Jack Tar Hotel, San Francisco.
The Workshop is a function of the extension division of the
San Francisco Psychoanalytic Institute.

Dr. Winnicott and a panel of psychoanalysts, pediatricians,
teachers and social workers will discuss care for the child
in normal circumstances as well as in situations complicated
by individual family and community crises. The fee for
registration is $10. Registration forms can be obtained by
writing to Miss Jennie Chiado, executive secretary, San
Francisco Psychoanalytic Institute, 2380 Sutter Street, San
Francisco 15.

GENERAL

The State Board of Public Health will hold hearings to
consider proposed regulations to prohibit use of the Hoxsey
Method for treatment of internal cancer on August 22
at 10:00 a.m. in Room 1122, State Office Building, 107 South
Broadway, Los Angeles, and on August 29, 1962 at 10:00
a.m. in Room 802, State Department of Public Health Build-
ing, 2151 Berkeley Way, Berkeley.

The regulations were developed upon the advice of the
Cancer Advisory Council of the California State Department
of Public Health.

Persons interested in the proposed regulations are invited
to attend the hearings.

The report of the Cancer Advisory Council is available
for inspection at the following places:

Bureau of Food and Drug Inspections, Room 7, B Street
Pier Building, San Diego.

Bureau of Food and Drug Inspections, Civic Center Build-
ing, Room 209, 157 West Fifth Street, San Bernardino.

Bureau of Food and Drug Inspections, Room 708, Cali-
fornia State Building, 217 West First Street, Los An-
geles.

Bureau of Food and Drug Inspections, 5545 East Shields
Avenue, Fresno.

Bureau of Chronic Diseases, Room 412, 2000 Hearst
Street, Berkeley.

Bureau of Food and Drug Inspections, 631 J Street, Sac-
ramento.

❖ ❖ ❖

The California Society of Anesthesiologists has an-
nounced the opening of competition for its annual award
to residents submitting the best papers on a clinical or
laboratory subject. The senior author must be a resident
physician training in anesthesiology in the State of Califor-
nia. Three prizes, one of $200, one of $75 and one of $50
are offered.

Papers must be submitted before November 30, 1962, to
Dr. Verne L. Brechner, division of anesthesiology, Univer-
sity of California Medical Center, Los Angeles 24.

130

CALIFORNIA MEDICINE

EDUCATION NOTICES

POSTGRADUATE

THIS BULLETIN of the dates of postgraduate education
programs and the meetings of various medical organ-
izations in California is supplied by the Committee on
Postgraduate Activities of the California Medical Asso-
ciation. In order that they may be listed here, please
send communications relating to your future medical or
surgical programs to Postgraduate Activities, California
Medical Association, 693 Sutter Street, San Francisco 2.

UNIVERSITY OF CALIFORNIA AT LOS ANGELES

Seminars in Internal Medicine. Sunday through
Wednesday, August 12 through 15. At University Resi-
dential Conference Center, Lake Arrowhead. Fee:
$137.50 includes room and meals for 3 days.
Pediatric Neurology. Wednesday through Sunday, Au-
gust 15 through 19. At University Residential Confer-
ence Center, Lake Arrowhead. Fee: $150.00 includes
room and meals for 4 days. 21% hours.

The Evaluation of Therapeutic Agents and Cosmet-
ics. Thursday through Saturday, August 16 through
18. 17 hours. Fee: $100.00.

The Endocrine Aspects of Obstetrics and Gynecol-
ogy. Thursday through Saturday, August 23 through
25. 21 hours. Fee: $60.00.

Teaching Clinics in Internal Medicine. Thursdays.

September 13 through December 6. Fee: $60.00.

A Basic Science Course in Ophthalmology. Wednes-
days. October 17, 1962, through April 17, 1963. Fee and
hours to be announced.

Clinical Traineeships. Anesthesia and Dermatology
and Pediatric Cardiology. Dates to be arranged. 2
weeks: $150.00; 4 weeks: $250.00. Minimum period,
2 weeks.

For information on courses for physicians or ancillary per-
sonnel contact: Thomas H. Sternberg, M.D., assistant
dean for Department of Continuing Education in Medi-
cine and Health Sciences, U.C.L.A. Medical Center, Los
Angeles 24. BRadshaw 2-8911, Ext. 7114.

UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

Athletic Medicine. Wednesday through Friday. August
29 through 31. *f

New Concepts in Arthritis. Thursday and Friday. Sep-
tember 6 and 7.*f

Internal Medicine — A Selective Review. Monday
through Friday. September 10 through 14.*!
Postgraduate Seminars in Clinical Sciences. Saturday
mornings. September 15 through November 17. Mercy
Hospital, Sacramento. No fee. 17% hours.
Psychotherapy in Medical Practice. Wednesdays. Sep-
tember 19 through December 5. Langley Porter Neuro-
psychiatric Institute. Fee: $25.00. 48 hours.

Clinics in the Surgical Specialties. Thursday through
Saturday. September 20 through 22. *f
Radiological Physics. Tuesday evenings. September 25
through April 14, 1963. Fee: $150.00. 48 hours.

•Fees to be announced.
tHours to be announced.

Neuropsychiatry in General Practice. Thursday eve-
nings. September 27 through November 1. Fee: $5.00.
12 hours.

Man to Man. Thursday evenings. September 27 through
November 15. 8 hours.*

Psychiatric Lecture Series. Saturday mornings. Sep-
tember 29 through November 3. Herrick Memorial Hos-
pital, Berkeley. Fee: $5.00. 12 hours.

Surgery. Saturday, September 29. Franklin Hospital, San
Francisco.*"]'

Glaucoma. Monday through Wednesday. October 1
through 3.*f

Pediatric Infections. Friday through Sunday. October
5 through 7.*f

Medicine in Industry. Wednesday and Thursday. Oc-
tober 10 and 11.*!

Drug Therapy in Clinical Practice. Friday and Sat-
urday, October 12 and 13.*!

Obstetrics and Gynecologic Surgery. Thursday
through Saturday. October 25 through 27. *f

Multiple Injuries and Trauma. Thursday and Fri-
day. November 1 and 2.*f

Problems in EKG Interpretation. Saturday and Sun-
day. November 3 and 4. Mount Zion Hospital, San
Francisco. *f

Clinics in Dermatology. Saturday and Sunday, Novem-
ber 10 and 11.*!

Psychiatry in General Practice — A Clinical Workshop.
Saturday and Sunday. November 17 and 18. Napa State
Hospital. Fee: $10.00. f

The Neck and Shoulder-Girdle. Friday and Saturday.
November 30 and December l.*f

Practical Electrocardiography. Friday and Saturday.
November 30 and December 1. Franklin Hospital, San
Francisco.*f

Psychiatric Perspectives in Medicine. Saturday and
Sunday. December 1 and 2. Stockton State Hospital.*!

Ocular Pharmacology and Therapeutics. Thursday
through Saturday. December 6 through 8.*!

Puberty and the Climactic. Friday and Saturday. De-
cember 7 and 8.*!

The Impact with the Disturbed Patient. Thursday
through Saturday. December 13 through 15. Langley
Porter Neuropsychiatric Institute.*!

Courses presented by Special Arrangement (continu-
ously) :

1. Principles and Clinical uses of Radioisotopes

(full time for one to three months).

For information on courses for physicians or ancillary per-
sonnel contact: Department of Continuing Medical Edu-
cation in Medicine and Health Sciences, University of
California Medical Center, San Francisco 22. MOntrose
4-3600, Ext. 665.

UNIVERSITY OF SOUTHERN CALIFORNIA,

LOS ANGELES

Basic Home Course in Electrocardiography. One year
postgraduate series, electrocardiogram interpretation by
mail. Physicians may register at any time and receive
all 52 issues. Fifty-two weeks. Fee: $100.00.

Advanced Home Course in Electrocardiography. One
year postgraduate series, electrocardiogram interpreta-
tion by mail. Fifty-two issues: $85.00. Physicians may
register at any time.

VOL. 97, NO. 2

AUGUST 1962

131

Intensive Review of Internal Medicine. Tuesday
through Saturday and Monday through Friday. Sep-
tember 4 through 14. 8:30 a.nt. to 12:30 p.m. Los Ange-
les County Hospital. Fee: $65.00.

Process-Oriented Psychotherapy. Tuesday evenings.
8:00 to 10:00 p.m. September 11 through October 30.
Veterans Center. Fee: $50.00.

Psychiatric Case Conferences for Family Physicians.

Beginning September 20. An integration of psychi-
atry into medicine. 16 weekly case conferences. Psychi-
atric Unit, Los Angeles County Hospital. Fee: $40.00.

Psychiatry in Medical Practice. September 22 and 23.
Two-day intensive workshop. San Diego County Gen-
eral Hospital. Fee: $25.00.

Redside Clinics and Set Clinics in Internal Medi-
cine. Thursday evenings. 7:30 to 9:30 p.m. October 4,
1962 through January 10, 1963. Los Angeles County
Hospital. Fee: $65.00.

Symposium on Neoplastic Diseases (Homecoming).
Thursday and Friday. November 1 and 2. Ambassador
Hotel. Fee. $25.00.

Psychiatry in Medical Practice. Saturday and Sun-
day. November 17 and 18. Santa Barbara County
General Hospital. Fee: $25.00.

Electrocardiographic Interpretation. Thursday
through Saturday. December 6 through 8. Statler-
Hilton Hotel. Los Angeles.

1963

Psychiatry in Medical Practice. January 12 and 13.
Two-day intensive workshop. San Bernardino County
General Hospital. Fee: $35.00.

Pediatric Psychiatry for General Practitioners and
Pediatricians. January 30 through April 10. Psychi-
atric Unit, Los Angeles County General Hospital. Fee:
$35.00.

Psychiatry Case Conferences for Medical Practi-
tioners. January 30 through April 10. Eleven sessions,
to be held simultaneously at St. John’s Hospital, Santa
Monica; Orange County General Hospital. Orange:
Memorial Hospital of Long Beach; Cedars of Lebanon
Hospital. Fee: $40.00.

Psychiatry Courses. Contact: Allen J. Enelow, M.D.,
associate clinical professor. Department of Psychiatry,
1934 Hospital Place, Los Angeles 33, CA 5-3131, Ext.
71951.

Contact: Phil R. Manning, M.D., Associate Dean and
Director, Postgraduate Division, University of Southern
California School of Medicine, 2025 Zonal Avenue, Los
Angeles 33. CApital 5-1511.

LOMA LINDA UNIVERSITY

Introductory Course in Surgery of the Nasal Sep-
tum and Closely Related Structures. Monday
through Thursday. October 29 through November 1.
Enrollment limited to 30. Fee: $150.00.

Clinical Traineeships available in clinical departments
by arrangement with Postgraduate Division and Post-
graduate Chairman of department involved. In addition
to those listed, other traineeships in other departments
can be arranged. Eighty hours minimum. Limited en-
rollment. Begin when individually arranged.

1. Anesthesia. Six months. 250 to 300 hours. Fee:

$350.00.

2. Pulmonary Diseases (can be arranged).

Continuously: Illustrated Medical Lectures. Thirty-

minute tape recordings and accompanying 35 mm.
filmstrips, 50 to 80 full-color pictures for screen, hand
or desk viewer. Available individually or by subscrip-
tion. Twelve or 36 titles per year, all titles produced
in one year in any chosen specialty. Projectors and
viewers included in subscription plans. Contact: Loma
Linda University, Illustrated Medical Lectures, Los
Angeles 33.

For information contact W. F. Norwood, Ph.D., Assistant
Dean and Chairman, Division of Continuing Education,
Loma Linda University School of Medicine, 1720
Brooklyn Ave., Los Angeles 33. ANgelus 9-7241, Ext.
214.

PRESBYTERIAN MEDICAL CENTER

Gastroenterostomy. Saturday, November 10. 7 hours.
Fee: $25.00.*

Pediatrics. Saturday, December 1. 7 hours. Fee: $25.00.*

Diabetes and Thyroid. Saturday, January 12, 1963. 7
hours. Fee: $25.00.*

Arteriosclerosis. Saturday, January 19, 1963. 7 hours.
Fee: $25.00.*

Dermatology. Saturday, February 2, 1963. 7 hours. Fee:
$25.00.*

Operable Heart Disease. Friday and Saturday. March
1 and 2, 1963. 14 hours. Fee: $25.00.

Office Diagnosis. Saturday, March 9, 1963. 7 hours.
Fee: $25.00.*

Cancer. Saturday and Sunday. March 16 and 17, 1963.
14 hours. Fee: $25.00.

Fractures: “4-R’s.” Saturday, March 23, 1963. 7 hours.
Fee: $25.00.*

Minor Surgery: Office and Hospital. Saturday, April
6, 1963. 7 hours. Fee: $25.00.*

Contact: Arthur Selzer, M.D., Chairman, Education Com-
mittee, Presbyterian Medical Center, Clay & Webster
Streets. San Francisco 15. WEst 1-8000.

CALIFORNIA MEDICAL ASSOCIATION

POSTGRADUATE CIRCUIT COURSES

Sacramento Valley Counties Postgraduate Circuit
Courses in Dunsmuir, Redding, Chico and Auburn in
cooperation with Stanford University School of Medi-
cine. 8 monthly meetings beginning week of Sep-
tember 10.

North Coast Counties Postgraduate Circuit Courses in
Eureka and Ukiah, in cooperation with the University
of California School of Medicine, San Francisco. 8
monthly meetings beginning week of September 10.

For information regarding Postgraduate Circuit Courses
and Postgraduate Institutes, contact: Postgraduate Ac-
tivities, California Medical Association, 693 Sutter
Street, San Francisco 2. PRospect 6-9400, Ext. 68.

AUDIO-DIGEST FOUNDATION

*These courses will be offered at $25.00 per course or 4
courses for $80.00 or 8 courses for $120.00. Operable Heart
Disease and Cancer courses not included.

132

CALIFORNIA MEDICINE

Representing tape-recorded highlights of the past year's
most significant medical meetings (American Medical
Association, American College of Physicians, American
Society of Anesthesiologists, American College of Ob-
stetricians and Gynecologists, and dozens of university
postgraduate courses) the new Catalog lists 355 one-
hour tape-recordings representing all areas of medical
practice. Copies of the catalog and information con-
cerning continuing subscriptions to Audio-Digest
programs (General Practice, Obstetrics-Gynecology,
Anesthesiology, Pediatrics, Internal Medicine and Sur-
gery and a prospective new service in Ophthalmology-
Otorhinolaryngology) may be obtained by writing to
Claron L. Oakley, Editor, 618 South Westlake Avenue,
Los Angeles 57.

Medical Dates Bulletin

Reno Surgical Society, Reno, Nevada. August 23
through 25. Contact: Donald F. Guisto, M.D., program
chairman, 506 Humboldt Street, Reno.

National Kidney Disease Foundation, Southern Cali-
fornia Chapter, Second Annual Symposium. September
13. Ambassador Hotel. Los Angeles. 9:00 a.m. to 5:00
p.m. Contact: Mrs. Jean Gordon, administrative as-
sistant.

St. John’s Hospital Postgraduate Assembly. Septem-
ber 13 through 15. Contact: John C. Eagan, M.D., di-
rector, St. John’s Hospital, 1328 22nd Street, Santa
Monica.

Ventura County Heart Association and Santa Bar-
bara County Heart Association 7th Annual Sympo-
sium on Cardiovascular Disease. Santa Barbara Bilt-
more Hotel. September 22, 9:00 a.m. to 5:00 p.m. Con-
tact: Robert E. Wolf, executive director, Ventura
County Heart Association, 848 Santa Clara, Ventura,
or Mrs. Sara Clyde, executive director, Santa Barbara
County Heart Association, 18 La Arcada Ct., Santa
Barbara.

Los Angeles County Heart Association 32nd Annual
Professional Symposium on Heart Disease. Statler Hil-
ton Hotel, Los Angeles. September 26 and 27. Contact:
Chauncey A. Alexander, executive director, L. A.
County Heart Association, 2405 W. 8th Street, Los
Angeles 57.

San Francisco Heart Association 32nd Annual Post-
graduate Symposium on Heart Disease. St. Francis
Hotel, San Francisco, September 26 through 28, 9:00
a.m. to 5:00 p.m. Contact: Gene C. Taylor, executive
director, San Francisco Heart Association, 259 Geary
Street, San Francisco 2.

San Diego County Heart Association 12th Annual Pro-
fessional Symposium on Heart Disease. Town and Coun-
try Hotel, San Diego. September 28 and 29. Contact:
Mr. 0. M. Avison, executive director, 3545 4th Avenue,
San Diego 3.

American Society of Plastic and Reconstructive Sur-
gery, Hawaiian Village Hotel, Honolulu. Contact: T.
Ray Broadbent, M.D., secretary, 508 E. South Temple,
Salt Lake City. October (dates to be announced).

The Pacific Coast Fertility Society 11th Annual Con-
vention at the Mountain Shadows Hotel, Scottsdale
(Phoenix), Arizona, October 4 through 7. Contact:
Gregory Smith, M.D., secretary, 909 Hyde Street, San
Francisco 9.

California Congress on Medical Quackery. Del Webb
Towne House, San Francisco. October 10. Contact:
Eugene G. Miller, M.D., 693 Sutter Street, San Fran-
cisco.

Annual Meeting, California Division of the Ameri-
can Cancer Society, October 11 and 12. Del Webb
Towne House, San Francisco. Contact: Mr. Robert Mur-
phy, 875 O'Farrell Street, San Francisco.

Western Industrial Medical Association. Jack Tar Ho-
tel, San Francisco. October 12 and 13. Contact: B. M.
Brundage, M.D., secretary, Atomics International. P. O.
Box 309, Canoga Park, Calif.

Western Institute on Epilepsy 14th Annual Meetinc.
October 19 through 20. Sir Francis Drake Hotel, San
Francisco. Contact: Bill Garoutte, M.D., chairman,
U.C. Medical Center, 3rd and Parnassus Avenues, San
Francisco 22.

Kaiser Foundation Hospital’s Sixth Annual Sympo-
sium. “The Flow of Life.” October 19 and 20. Fairmont
Hotel, San Francisco. Contact: Amos Lieberman, M.D.,
director of Medical Education, Kaiser Foundation Hos-
pital, 2425 Geary Street, San Francisco.

American Fracture Association. October 20 through
25. Huntington-Sheraton Hotel, Pasadena. Contact: H.
W. Wellmerling, M.D., secretary-general, 610 Griesheim
Bldg., Bloomington, Illinois.

American Epilepsy Federation Annual Meeting. Octo-
ber 21. Sir Francis Drake Hotel, San Francisco. Con-
tact: Mrs. Fred S. Markham, program chairman, c/o
California Epilepsy Society, 4343 Crenshaw Blvd., Los
Angeles 8.

California Academy of General Practice Annual
Meeting. Masonic Memorial Temple, San Francisco.
October 21 through 24. Contact: Mr. William W.
Rogers, executive secretary, 9 First Street, Room 900,
San Francisco 5.

Kern County General Hospital Second Annual Post-
graduate Conference and Alumni Day. October 26.
Contact: George A. Paulsen, M.D., chairman, Confer-
ence Committee, Kern County General Hospital, 1830
Flower Street, Bakersfield.

California Society of Internal Medicine Annual
Meeting. October 26 through 28. Mark Thomas Inn,
Monterey. Contact: Robert L. Paver, M.D., secretary-
treasurer, 350 Post Street, San Francisco 8.

Western Orthopaedic Association. October 28 through
November 1. Fairmont Hotel, San Francisco. Contact:
Mrs. Vi Mathiesen, executive secretary, 351 21st Street,
Oakland 12.

Nevada State Medical Association 59th Annual Meet-
ing. October 31 through November 3. Stardust Hotel,
Las Vegas. Contact: Nelson B. Neff, executive secretary,
Nevada State Medical Association, 506 Humboldt
Street, Reno, Nevada.

American Rhinolocic Society 8th Annual Meeting.
Statler Hilton Hotel, Los Angeles. November 1 and 2.
Contact: American Rhinologic Society, 530 Hawthorne
Place, Chicago 13.

TB & Health Association of Los Angeles County
Symposium on the Techniques of Teaching Diseases of
the Chest. November 3. Sheraton West Hotel, Regency
and Wedgewood Rooms, Los Angeles. 8:30 a.m. to
3:30 p.m. Contact: Oscar J. Balchum, M.D., chairman.
Planning Committee, c/o TB & Health Assoc, of Los
Angeles County, 1670 Beverly Blvd., Los Angeles 26.

VOL. 97. NO. 2

AUGUST 1962

133

1963 MEETINGS

American Academy of Ophthalmology and Otolaryn-
cology, Las Vegas Convention Center, Las Vegas. No-
vember 4 through 9. Contact: W. L. Benedict, M.D.,
executive secretary-treasurer, 15 Second Street, S.W.,
Rochester, Minn.

Los Angeles Pediatric Society 19th Annual Brenne-
mann Lectures, Ambassador Hotel, Los Angeles.
Speakers: Albert B. Sabin, M.D., and Malcolm A. Hol-
liday, M.D. November 7 and 8. Contact: Leslie M.
Holve, M.D., vice-president, 1015 Gayley Avenue, Los
Angeles 24.

San Diego County General Hospital 16th Annual Post-
graduate Assembly, in conjunction with University of
Oregon Medical School. November 9 and 10. Town and
Country Hotel, San Diego. Contact: David E. Wile,
M.D., chairman, 2850 6th Avenue, San Diego 3.

California Conference of Local Health Officers
Biannual Meeting. Riverside County Health-Finance
Building. November 13-14. Contact: Wm. Allen Long-
shore, Jr., M.D., asst, chief, Division Community Health
Services, State Dept, of Public Health, Berkeley.

American College of Physicians, Southern California
Region Annual Basic Science Lectureship Dinner. Stat-
ler Hotel, Los Angeles, November 14, 6:30 p.m. Con-
tact: George C. Griffith, M.D., A.C.P. Governor for
Southern California, P. 0. Box 25, 1200 North State
Street, Los Angeles 33.

American College of Chest Physicians (Interim Ses-
sion). November 24 and 25. Ambassador Hotel, Los An-
geles. Contact: Mr. Murray Komfeld, executive director,
112 E. Chestnut Street, Chicago 11.

American Medical Association Clinical Meeting, Los
Angeles. November 25 through 28. Contact: F. J. L.
Blasingame, M.D., executive vice-president, 535 N.
Dearborn, Chicago 10.

American Medical Women’s Association, Ambassador
Hotel, Los Angeles. November 29 through December 2.
Contact: Jessie Laird Brodie, M.D., executive director,
1790 Broadway, New York 19.

West Coast Allergy Society, Annual Meeting. Decem-
ber 1. Portland, Oregon. Contact: Mr. J. M. Chesebro,
executive secretary, 1818 S.E. Division Street, Portland.

San Diego County Heart Association First An-
nual Postgraduate Seminar on Heart Disease. Feb-
ruary 4 through 8. Featured Teacher: Pane Wood,
M.D., London, England. Contact: Mr. 0. M. Avison,
executive director, San Diego County Heart Assoc.,
3545 - 4th Avenue, San Diego 3.

Institute Metabolic Research 11th Annual Session.
“Dynamics of Endocrine and Metabolic Diseases.” Feb-
ruary 11 through 13. Highland-Alameda County Hospi-
tal, Main Auditorium, Oakland. Contact: L. W. Kinsell,
M.D., director, Institute of Metabolic Research.

American College of Physicians Southern California
Regional Meeting, Hotel Del Coronado, Coronado. Feb-
ruary 15 through 17. Submit abstract of 300 words or
less on or before November 1, 1962, to Walter P. Mar-
tin, M.D., 211 Cherry Avenue, Long Beach 2. Contact:
George C. Griffith, M.D., Governor for Southern Cali-
fornia, A.C.P., P.O. Box 25, 1200 North State Street,
Los Angeles 33.

American College of Cardiology 12th Annual Meeting.
February 28 through March 3. Ambassador Hotel, Los
Angeles. Contact: Philip Reichert, M.D., executive
director, Empire State Building, 350 - 5th Ave., New
York 1.

Loma Linda University School of Medicine Alumni
Postgraduate Convention. March 3 through 7. Re-
fresher Courses: March 3 and 4, 8:00 a.m. to 12:00
noon; 2:00 p.m. to 5:00 p.m. White Memorial Medical
Center. Scientific Assembly: March 5 through 7, Am-
bassador Hotel. Contact: Jack Hallatt, M.D., general
chairman, 316 N. Bailey St., Los Angeles 33.

California Medical Association Annual Session.
March 24 through 27. Ambassador Hotel, Los Angeles.
Contact: John Hunton, executive secretary, California
Medical Association, 693 Sutter Street, San Francisco 2.

TB & Health Association of California Annual Meet-
ing. April 4 through 6. Villa Hotel, San Mateo. Contact:
William W. Phreaner, coordinator, Public Relations,
130 Hayes Street, San Francisco 2.

American Gastroenterological Association. May 30
through June 1. Fairmont Hotel, San Francisco. Con-
tact: Wade Volwiler, M.D., Department of Medicine,
University of Washington, Seattle.

134

CALIFORNIA MEDICINE

Psychic Factors Found
In Bleeding Disorder

Emotional problems appear to be related to
chronic purpura, a bleeding disorder, in much the
same way that psychological factors have been
linked to bleeding stigmata, according to Drs. David
P. Agle and Oscar D. Ratnoff, Cleveland.

A study of nine women with purpura, a condition
in which blood spreads abnormally into the skin
and creates purple areas, revealed that all had previ-
ously experienced hysterical symptoms, the two
physicians wrote in the June Archives of Internal
Medicine, published by the American Medical Asso-
ciation.

The emotional background of these patients “dis-
plays similarities to that previously described in
some individuals with bleeding stigmata,” they said.

Perhaps the most extensively studied stigmatized
individual of this century has been Theresa Neu-
mann of Konnersreuth, the authors pointed out.
Prior to the first appearance of the stigmata, repro-
ducing the wounds of Christ, Miss Neumann had
alternating episodes of blindness, deafness, convul-
sions, bleeding, and paralysis, they said.

Similar episodes have been described in Moham-
medans in whom bleeding simulating the battle
wounds of their prophet have appeared during times
of deep contemplation, they said. A number of case
reports describe bleeding episodes unrelated to

religious experience in patients with various emo-
tional problems, they said.

Their own study suggests that “purpuric bouts”
occur at times of emotional stress, the two research-
ers said. Among stresses reported in the nine pa-
tients were fear, resentment, anxiousness, despair,
and anger directed outwardly and inwardly, they
said.

Eight of the group admitted that they bad severe
problems in their relationship to members of their
family, they said. Bleeding symptoms disappeared
in two patients after their husbands died, they said.

In addition to hysterical reactions, such as hallu-
cinations, loss of speech and paralysis, they said,
the patients also demonstrated masochistic traits,
i.e., an actual enjoyment of hardship.

The authors said they planned further investiga-
tions of influence of emotional factors on bleeding
episodes in known organic diseases, such as hemo-
philia.

Dr. Agle is affiliated with University Hospitals of
Cleveland. Dr. Ratnoff is professor of medicine.
Western Reserve University School of Medicine.

A Gordh Needle for Infants — P. J. Horsey. Lancet —
Vol. 1:622 (March 24) 1962.

An indwelling intravenous needle has been designed to
fit conveniently on the back of the hand of children and
infants. It is particularly useful in children undergoing
cardiac catheterization. Its over-all length is 3 cm.

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and your colleagues have saved since 1935 in just four diseases— tuberculosis, syphilis, influenza and
pneumonia. And among working-age victims 2,000,000 are alive today who would not have survived
if the 1935 death rate had remained constant.

In the past 25 years, new and potent drugs have played a significant role in reducing mortality
from these diseases. Such an achievement results from the combined efforts of many organizations,
professions and enterprises . . . including people working in medical and pharmaceutical research, pro-
duction, and distribution, who make drug products available to doctors and dentists, hospitals and
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CALIFORNIA MEDICINE

Graduate Courses Offered
For Teachers in Nursing Field

Three universities in California offer graduate
programs which prepare teachers for all types of
educational programs in nursing and administra-
tors, supervisors and clinical nursing experts for
nursing service agencies. To meet future needs for
leadership personnel in nursing it is estimated that,
by 1975, approximately 700 nurses should complete
masters and higher degree programs in nursing
and related fields. In 1960 less than 100 nurses
completed such programs.

It is estimated that, at present, 95 per cent of
teachers in basic nursing programs, 57.5 per cent
of public health nurses and 12 per cent of hospital
nurses hold one or more college degrees. Of the
teachers in baccalaureate and higher degree pro-
grams 77 per cent hold masters degrees and 4 per
cent hold doctors degrees; of those in associate
degree programs 41 per cent hold masters degrees
and of those in diploma programs 21 per cent hold
masters degrees.

Of registered nurses in California 55.5 per cent
are employed in hospitals, 13.1 per cent in office
nursing, 11.3 per cent in private duty, 9.1 per cent
in public health and school nursing, 3.4 per cent in
industrial nursing, 2.1 per cent in schools of nurs-
ing, and the remainder in various type of positions.

Of licensed vocational nurses 68 per cent are em-

ployed in hospitals, 21.5 per cent in private duty
and home nursing, 18 per cent in clinics and out-
patient departments, 15.5 per cent in nursing homes
or sanitariums, 10 per cent in physicians offices, 3
per cent in nursery schools and 3 per cent in visiting
nursing in homes.

From a survey of over 6,000 nurses employed in
hospitals in 14 counties in California in 1960 it was
found that 52 per cent were married, 28 per cent
were single and 20 per cent were widowed or di-
vorced. Of these nurses 34 per cent were under 30,
47 per cent were between 30 and 49, and 19 per
cent were 50 years or over.

Physical Activities Studied
In Rheumatic Heart Patients

Restriction of physical activities in certain pa-
tients following rheumatic fever may serve “no use-
ful purpose,” a study reported in the June 23 Jour-
nal of the American Medical Association suggested.

The observation applies only to patients who
have recovered from an acute attack of rheumatic
fever without serious heart damage, according to
Drs. Alvan R. Feinstein, Harry Taube, Ralph Cava-
lieri, Stanley C. Schultz, and Lawrence Kryle, New
York City. Restrictions on activities in such patients
are aimed at preventing heart damage, they said.

A total of 216 patients who had recovered from
(Continued on Page 51)

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Pennsylvania M.J. 59:808 (July) 1956. 2. Matlin, E.: M. Times
84: 68 (Jan.) 1956. 3. Hodge, J., Sokoloff, M., and Franco, F.:
Am. Pract. & Digest Treat. 10: 473 (March) 1959. 4. Burros,
H. M., and Borromeo, V. H. J.: J. Urol. 76:456 (Oct.) 1956.

5. Lane, R. A.: New York J. Med. 55:2343 (Aug. 15) 1955.

6. Weston, D.T.: Journal-Lancet 76:7 (Jan.) 1956. 2/3oo5»b

For complete information about Doriden (including dosage,
cautions, and side effects), see the current Physicians’ Desk
Reference or write CIBA, Summit, N. J.

Doriden

(glutethimide ciba)

B A Summit, N.J.

CALIFORNIA MEDICINE

Physical Activities Studied
In Rheumatic Heart Patients

(Continued from Page 49)

rheumatic fever were studied in an effort to deter-
mine whether physical and scholastic restrictions
were related to the progression or development of
heart disease, they said.

All of the patients were “asymptomatic,” that is,
they may have had abnormal heart murmurs, x-rays,
or electrocardiograms, but strenuous exercise pro-
duced no noticeable discomfort, they said. The
patients were examined annually at the Irvington
House After-Care Clinic for an average of 21 years
after their attack of rheumatic fever, they said.

The results indicated that improvement or deteri-
oration in the patients’ heart condition had no
direct relationship to the presence or absence of
restrictions on activities, the researchers said.

Among 141 patients whose school activities had
been restricted, the heart condition of 86 per cent
remained unchanged or improved while in 14 per
cent it become worse, they said. Of 75 patients with
no school restrictions, the heart condition remained
the same or improved in 92 per cent while it became
worse in 8 per cent, they said.

The heart condition became worse in 15 per cent
of 66 patients whose after school hours activities
were restricted and in 11 per cent of 150 who ob-
served no such restrictions, they said.

After completion of schooling, worsened heart
conditions were found in 14 per cent of 42 patients
who observed restrictions and in 11 per cent of 174
patients who did not, they said.

Psychosocial aspects of restriction of activities
also were studied, the researchers said. The findings
indicated that in some cases restrictions had adverse
effects on scholastic, occupational and marriage
plans, they said.

“These results suggest that no useful purpose is
served by many of the scholastic, athletic, voca-
tional, and other physical restrictions that are often
imposed upon the asymptomatic post-rheumatic
fever patient,” the authors concluded.

“These restrictions do not seem to prevent or to
augment cardiac deterioration and they may create
unpleasant psychosocial effects that negate any of
the anticipated medical advantages.”

Amodiaquine Hydrochloride in Treatment of Chronic
Discoid Lupus Erythematosus — A. Maguire. Lancet —
Vol. 1:665 (March 31) 1962.

Seventeen patients were treated for chronic discoid lupus
erythematosus with amodiaquine hydrochloride. All patients
were of marked chronicity and in the past had received at
least one other antimalarial drug. Sixteen had a good re-
sponse to the drug, and in some the response was dramatic
and excellent. Few serious side effects were observed. The
dosage appeared to be not more than 200 mg. daily, and
usually 200 mg. 3 times a week sufficed.

LESS BICARBONATE LOSS

LESS ALTERATION
IN URINARY pH

1. Cohen, B. M.: M. Times 88:855 (July) 1960. 2. Cohen, B. M.: Med. et Hyg. (Geneve) #494, p. 210
(Mar. 15) 1961.

Naturetin —the diuretic with specific difference

SQUIBB BENDROFLUMET HI AZIDE

Squibb

Squibb Quality — the Priceless Ingredient

n DIVISION

Clin

Advertising • AUGUST 1962

only 2 seconds
to specify
maximum

Only 2 seconds are needed to write, “Thyroid Armour ’
on a prescription: a small investment in time, but one
that offers big advantages to your patients. In Thyroid
Armour you get maximum quality insured by consist-
ently high standards of preparation. Over 75 years’
experience is behind the Armour brand.

THYROID U. S. P.

Thyroid Tablets (Armour) are prepared from fresh selected glands, desiccated and standardized by
official U.S.P. method to contain 0.2 per cent of iodine in thyroid combination. Thyroid Powder U.S.P.
(Armour) is standardized and of uniform potency. USES: Thyroid deficiencies, cretinism, myx-
edema, nodular goiter (nontoxic), non-nodular goiter. A variety of clinical conditions will respond
to the use of Thyroid (Armour) when subclinical hypothyroidism is involved. DOSAGE: X to 5
grains daily as required by clinical condition. Therapeutic effect develops slowly and lasts for two
months or longer. Thus the daily dose may be given as a single dose (preferably in the morning)
rather than several times daily. Patients treated with thyroid should be continuously under the
physician’s observation. CONTRAINDICATIONS: Heart disease and hypertension, unless the
metabolic rate is low. SUPPLIED: Tablets— bottles of 100, 1000 and larger; potencies of X» X. 1»
2 and 5 grains. Powder— 1 oz., 4 oz. and 1 lb. bottles.

ARMOUR PHARMACEUTICAL COMPANY
kankakee, iluinois • Originators of Listica ®

CALIFORNIA MEDICINE

makes glaucoma screening easier

"Since approximately 3 to 4 per cent of those patients in the forty-and-over age group may have
glaucoma, the value of a routine measurement of the intraocular pressure is self-evident."1

Screening tonometry for early detection of glaucoma can be incorporated conveniently into any physical
examination procedure when the eye is anesthetized with OPHTHAINE, the topical anesthetic with the
shortest onset time. Instillation of 1 or 2 drops produces adequate anesthesia in approximately 20 seconds
or less.2'3 OPHTHAINE anesthesia is completely safe, because the drug does not damage the corneal
epithelium and seems to be less irritating than other agents.4'5 6 The duration of anesthesia (about 15
minutes) is adequate forremoval of foreign bodies and similar operative procedures. In fact, the proper-
ties of OPHTHAINE make it ideal for any ophthalmologic procedure requiring topical anesthesia,
t

SUPPLY: Ophthaine is supplied as a sterile 0.5% solution in plastic drop-dispensing bottles containing 15 cubic centi-
meters. REFERENCES: 1 . Gordon, D.M.: /Vew YorkJ. Med. 61:3649 (Nov. 1) 1961. 2. McIntyre, A.R.; Lee, L.W.; Rasmussen, J.

A.; Kuppinger, J.C., and Sievers, R.F.: Nebraska State M.J. 35:100 (Apr.) 1950. 3. Boozan, C.W., and Cohen, I.J.: Am.

J. Ophthat. 36:1619 (Nov.) 1953. 4. Jervey, J.W.: South M.J. 48:770 (J u I y) 1 955. 5. Leopold, I.H.: in Modell, W.: Drugs of
Choice, 1960-1961, St. Louis, C.V. Mosby Co., 1960, page 699. 6. Linn, J.G., Jr., and Vey, E.K.: Am. J. Ophthat.

40:697 (Nov.) 1955

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Type of Hand Not Related
To Talent, Strength

The size of a person’s hand is not significantly
related to its strength or ability, according to an
article in the July Today's Health , published by the
American Medical Association.

“Among musicians, physicians, artists, athletes,
and all others who depend on their hands to earn
a living there is an infinite variety of stubby fingers,
slender fingers, large hands, and small hands,” the
article said.

Directed by a disciplined, determined brain, hu-
man fingers can be trained to perform amazing
feats, it said. A master pianist can strike 120 notes
per second, it said, and a skilled surgeon can tie
strands of silk thread into tight knots inside the
human heart with two fingers.

The hands are the busiest, most complex instru-
ments of the entire body, and the thumb is the
busiest and most important of its digits, according
to the article entitled “What Science Knows About
Your Hands.”

“Because of the thumb’s unique ability to cross
over and link up with any one of the other fingers
for a pinch, grab, or squeeze, we can get along with
one thumb and one other finger,” it said. “In a
serious hand injury, surgeons try first to save the
thumb.”

The other fingers are markedly different in
strength, the article pointed out.

“In the average person, the middle finger is the
strongest, followed in order by the index finger,
the fourth finger and the little finger,” it said.
“Fingers two and three are the fastest of the five.
The little finger is the slowest, but finger four is
considered by teachers of music and typewriting to
be the least responsive to training because of an
innate muscular weakness.”

Because of its intricate arrangement of nerves
and muscles, the hand is highly vulnerable to any
injury, the article said. Even a sprained finger
should be properly splinted for two to three weeks
or painful swelling may continue for months, it
said.

Falling with a glass bottle can cause such terrible
cuts that small children should never be permitted
to play with or be sent on errands with glass con-
tainers, it said.

“Our hands deserve careful treatment,” the ar-
ticle said. “As tools of learning, working, and com-
municating, they can be considered the fundamental
vehicle of human thought — partner with the brain
in forever separating man from the rest of the
animal kingdom.”

The article was written by Evan McLeod Wylie.

ENDOCRINOLOGY IN GENERAL PRACTICE

THE HOUSE OF ETHICAL
PHARMACEUTICALS

We would like to take this opportunity
of inviting you to attend one of our highly
informative classes dealing with Endocrin-
ology in General Practice.

Our classes, as outlined in the booklet
shown at the left, are designed to present
the most current up-to-date information on
such problems as endocrine disorders and
metabolic imbalance, cardiovascular condi-
tions, hypertension and neuroses, arthritis
and diabetes.

For a copy of this booklet and further
information on how to attend one of our
3-day courses, just send your name and ad-
dress to the Lanpar Company and we will
forward you all the necessary details.

LANPAR COMPANY • • • 2727 W. MOCKINGBIRD LANE • • • DALLAS 35, TEXAS

CALIFORNIA MEDICINE

Relieves

Anxiety

and

Anxious

Depression

The outstanding effectiveness and safety with
which Miltown relieves anxiety and anxious depres-
sion—the type of depression in which either tension
or nervousness or insomnia is a prominent symptom
— has been clinically authenticated time and again
during the past six years. This, undoubtedly, is one
reason why physicians still prescribe meprobamate
more often than any other tranquilizer in the world.

Miltown*

meprobamate (Wallace)

Usual dosage: One or two 400 mg. tablets t.i.d.

Supplied: 400 mg. scored tablets, 200 mg. sugar-coated
tablets; bottles of 50. Also as MEPROTABS® — 400 mg.
unmarked, coated tablets; and in sustained-release capsules
as MEPROSPAN®-400 and MEP ROSPAN®-200 (containing
respectively 400 mg. and 200 mg. meprobamate).

CM-6708

y WALLACE LABORATORIES / Cranbury, N. ].

Clinically proven
in over 750
published studies

IActs dependably —

without causing ataxia or
altering sexual function

Does not produce

2 Parkinson-like symptoms,
liver damage or
agranulocytosis

3 Does not muddle
the mind or affect
normal behavior

Advertising •

AUGUST 1962

for your young patient with

• Emotional Problems

• Learning Difficulties

DEVEREUX SCHOOLS IN CALIFORNIA

ROBERT G. FERGUSON, Ed.D., Director
KEITH A. SEATON, Registrar
KENNETH L. GREVATT, M.D., Medical Director
RICHARD H. LAMBERT, M.D., Psychiatric Director

You are invited to write
for our recent brochure.

Box 1079, Santa Barbara

THE
DEVEREUX
FOUNDATION

Devon, Pennsylvania
Santa Barbara, California
Victoria, Texas

FIFTY YEARS OF SERVICE TO CHILDREN

HELENA T. DEVEREUX EDWARD L. FRENCH, Ph.D.
Founder and Consultant President and Director

SCHOOLS

COMMUNITIES

CAMPS

TRAINING

RESEARCH

Yogis Able to Make Pulse Inapparent

Yogis are able to accomplish “amazing tricks with
their pulse rate and blood pressure,” according to
Dr. Albert Salisbury Hyman, New York City.

Yogis are followers of yoga, a Hindu philosophy
of mental discipline.

In a letter to the June 16 Journal of the American
Medical Association, Dr. Hyman said a study he
made 35 years ago showed that no pulse could be
detected at the wrist of a trained Yogi who “willed
the pulse to stop.”

Since Yogi methods teach selective muscle con-
traction and relaxation, it is mechanically possible
for them to stop or diminish the pulse, he said. A
Yogi can constrict the main artery leading to the
arm by contracting certain upper chest muscles,
he said.

Age Is No Bar to Cataract Surgery

Old age is no barrier to the surgical correction
of cataracts, according to an editorial in the June 23
Journal of the American Medical Association.

A cataract is an opacity of the lens of the
eye which results in loss of sight when the lens
becomes entirely opaque. A cataract generally re-
sults from the gradual degeneration of the lens
tissues and occurs most commonly in older persons.
The condition can be corrected by the sugical re-
( Continued on Page 58)

SEEKS PHYSICIANS

for Psychiatric and General Medical
assignments in State facilities of the De-
partments of Mental Hygiene, Correc-
tions, Youth Authority.

Offering liberal salaries, a variety of
professional placement, and selection of
locale. No written examination. Inter-
views in San Francisco and Los Angeles
twice monthly.

Write tor details to:

Medical Personnel Services,
Dept. SS,

State Personnel Board,

801 Capitol Avenue,
Sacramento, California

CALIFORNIA MEDICINE

In dealing with the chronic stress of arthritis the physician
often faces the problem of nutritional imbalance. High
potency B and C supplementation is needed for rapid
replenishment of tissue stores of these water-soluble vi-
tamins. STRESSCAPS meet this need and help support
the natural metabolic defenses in the disease. Supplied in
decorative “reminder'' jars of 30 and 100.

LEDERLE LABORATORIES, A Division of AMERICAN CYANAMID COMPANY, Pearl River, N. Y.

Each capsule contains:

Vitamin B, (Thiamine Mononitrate)

10 mg.

Vitamin B2 (Riboflavin)

10 mg.

Niacinamide

100 mg.

Vitamin C (Ascorbic Acid)

300 mg.

Vitamin B6 (Pyridoxine HCI)

2 mg.

Vitamin B12 Crystalline

4 mcgm.

Calcium Pantothenate

20 mg.

Recommended intake: Adults, 1 capsule daily,
or as directed by physician, for the treatment
of vitamin deficiencies.

STRESSCAPS

Stress Formula Vitamins Lederle

New Approach Reported to Acne Therapy

A drug chemically related to the female sex hor-
mone estrogen has been found to suppress oiliness
in the skin and alleviate acne, according to Dr.
Walter C. Herold, Colorado Springs, Colo.

In a preliminary report on a study involving 27
acne patients, Dr. Herold said the drug, 16-epiestriol-
3-allyl ether, was found capable of decreasing se-
baceous gland activity.

His report was published in the May Archives of
Dermatology, published by the American Medical
Association.

As anticipated, Dr. Herald said, a definite corre-
lation between the amount of oil and the degree of
acne was found. As the oil decreased he said, the
acne decreased.

Treatment of acne has been directed mainly to-
ward removing or covering up excessive amounts
of oil, he said, but it is much more satisfactory to
decrease or eliminate the formation of excessive oil
in the first place.

Of 17 men and 10 women studied, he said, most
were under treatment for several months.

Only three patients failed to show any improve-
ment, he said. Ten showed marked improvement
and 10 moderate improvement, he said.

Observed complications were minimal, he said.

“This drug could prove extremely valuable in an

appreciable number of well-chosen patients and
therefore warrants thorough investigation,” Dr.
Herold concluded.

Age Is No Bar to Cataract Surgery

(Continued from Page 56)

moval of the clouded lens after which cataract
glasses are prescribed to replace the natural lens.

“Old age is never a contraindication to cataract
surgery,” Dr. Charles V. Barrett, Evanston, 111.,
said in a signed JAMA editorial. “Certainly, there
are few contraindications to cataract surgery. The
patient actually requires only a modicum of health
and a need for improved vision.”

Barring complications, he said, cataract surgery
is a “relatively benign procedure from start to
finish.”

In the premodern era, Dr. Barrett said, multiple
operations for the condition were not unusual.
However, he said, the present-day procedure is
becoming increasingly easier and safer.

The patient usually is up the day after the opera-
tion and goes home within a week, he said.

“The restoration of vision in the aged does much
toward the maintenance and improvement of the
other faculties of mind and body,” Dr. Barrett said.
“Many an allegedly psychotic older patient has
returned to reality through the medium of cataract
surgery.”

Birtcher Ultrasonics

lease now for only
40c a day

for a new booklet of facts on leasing
medical equipment call or write :

Mr. Chet Cardell
P.0. Box 4212
Santa Barbara, Calif.
WO 2-0178

3246 Telegraph Avenue
Oakland 9, Calif.
OLympic 4-5680

James Gilmer
3150 El Cajon Blvd.

San Diego 4, Calif.

AT 3-3436

4371 Valley Boulevard
Los Angeles 32, California
CApitol 2-9101

Exchisive: Only Birtcher
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xvhich adjusts instantly
to any of 5 positions.

The remarkable new Birtcher Lease plan puts the finest ultrasonic unit
made in your office for just 40 cents a day. Forty thousand physicians'
successful treatment of more than one million patients proves the value
of ultrasonics as adjunctive treatment of such common ailments as
Arthritis, Bursitis, Sinusitus, Herpes Zoster, Scleroderma, Dupuytren's
contracture, whiplash injury, strains, sprains, etc.

WHY BUY IF A LEASE COSTS LESS?

More physicians are leasing today because of these advantages: Less
cash outlay, no equipment obsolescence problems, no maintenance or
repair worries, use of money for other profitable investment, tax write
off of costs as operating expense, less capital puts more equipment in
an office, and the option to convert to purchase should an economic
situation change.

THE BIRTCHER CORPORATION

medical electronics for

CARDIOLOGY • ELECTROSURGERY • PHYSICAL MEDICINE
4371 Valley Blvd., Los Angeles 32, California

CALIFORNIA MEDICINE

Mr. B. is an energetic and
sociable man. His work and his
philanthropic, family, and
social obligations keep him
extremely busy. On Orinase, he
takes this life in stride.

The patient’s dosage had to be
increased in 1960 at the death of
his sister (also a diabetic).

For two months, maintenance of
control required 2.5 to 3.5 Gm.
of Orinase a day; dosage
then leveled off again at 1 Gm.

eye ailment, his need for
Orinase increased again. During
his wife’s convalescence, he
was taking 2.5 Gm. daily.

years of control

C nase* (tolbutamide) stands in a unique position; it alone,
a ong oral antidiabetes agents, has had five years or more
D lay-to-day routine clinical use in the hands of thousands
3 ahysicians throughout the country. Accordingly, data
3 a considerable number of truly long-term Orinase-
ti tted patients are now available. This series of Orinase
fi !-year case histories has been prepared to illustrate and
e smplify some aspects of actual experience in manage-

ment. Patient data, made available to us by physicians, have
been factually incorporated; however, patients’ identities
have been concealed. Any inquiries regarding this Orinase
case history series should be addressed to: Medical

Department, The Upjohn Company, Kalamazoo, Michigan.

Orinase is supplied in bottles of 50 and 200 tablets.
Each tablet contains: tolbutamide. . .0.5 Gm.
Reminder advertisement. Please see package insert
for detailed product information.

Upjohn

The Upjohn Company, Kalamazoo, Michigan

REFERENCES AND REVIEWS

Partial Gastrectomy with Jejunal Transposition: Fol-
low-Up Investigation of 80 Patients Treated Opera-
tively— U. Krause. Acta. Chir. Scand. — Vol. 123:132
(Feb.) 1962.

A series of 80 patients, 57 men and 23 women, with
gastric or duodenal ulcer were treated surgically by partial
gastrectomy with jejunal transposition, and were followed
up after intervals ranging from 8 months to 3% years.
Ulcer recurrences were recorded in 16% of the entire
series (22% of the duodenal ulcer patients and 14% of the
gastric ulcer patients). The brevity of the interval since
operation precludes any conclusions as to the incidence of
postcibal symptoms and anemia, although postcibal symp-
toms did occur in 5 cases between 1 and 3 years after the
operation. Jejunal transposition is rated as an excellent
method for use in certain cases of carcinoma of the stom-
ach and generally in cases in which total or subtotal gas-

trectomy is performed in achylic patients. If it is to be used
in normochylic or hyperchylic patients, however, the pro-
cedure should be combined with vagotomy. This applies
equally in cases of gastric ulcer.

* * *

Antibiotics and Gamma Globulin in Pseudomonas In-
fections— B. A. Waisbren and D. Lepley. Arch. Intern.
Med.— Vol. 109:712 (June) 1962.

Presented is a method of treatment of severe Pseudo-
monas aeruginosa infections by the intravenous administra-
tion of polymyxin B, oxytetracycline, and gamma globulin.
It is based on potentiation between polymyxin B and oxy-
tetracycline against Pseudomonas aeruginosa and the poten-
tiation of antibiotics by gamma globulin. The successful
treatment of a case of bacterial endocarditis and a case of
necrotizing papillitis, both due to Pseudomonas aeruginosa,
suggests that this regimen may be worth trying in infections
due to this bacteria that do not respond to other therapy.

3h is beautiful, heated swimming pool highlights
the spacious lawn and recreation area at
Camelback Hospital. Other outdoor activities
include volley ball, ping pong, shuffleboard and
badminton, all under the supervision of a trained

therapist. Those preferring restful relaxation may
enjoy a quiet conversation in the beautiful lawn
and grove area with its scenic mountain backdrop.

Located in the heart of the
beautiful Phoenix citrus area
near picturesque Camelback
Mountain, the hospital is
dedicated exclusively to the
treatment of psychiatric and
psychosomatic disorders,
including alcoholism.

Approved by the Joint Commission on
Accreditation of Hospitals; arid
The American Psychiatric Association

5055 North 34th Street
AMherst 4-4111
PHOENIX, ARIZONA
OTTO L. BENDHEIM, M.D., F.A.P.A., Medical Director

HAVE YOU CHANGED YOUR ADDRESS RECENTLY?

To insure uninterrupted delivery of your copies of California Medicine, please return this coupon properly
filled out. Address CALIFORNIA Medicine, 693 Sutter Street, San Francisco 2, California.

Name M.D.

(PLEASE PRINT)

Former address: New address:

Street Street

City City

Zone State — Zone State

(Please use this coupon for address change only)

Duplicate copies cannot be sent to replace those undelivered through failure to notify this office of change of address.

CALIFORNIA MEDICINE

Tranquilizer Prevents
Airsickness

Meprobamate, a mild tranquilizer, widely used,
“affords significant protection against airsickness,”
medical researchers reported in the July 21 Journal
of the American Medical Association.

John J. Franks, M.D., Lawrence J. Milch, Ph.D.,
and Elmer V. Dahl, M.D., Brooks Air Force Base,
Texas, tested the drug among 441 airmen who vol-
unteered for the study.

While a tranquilizer would not be desirable to
prevent motion sickness in pilots or combat per-
sonnel, they said, it might be useful for passengers
since the drug is noted for its low rate of adverse
side effects.

“Furthermore, it may not be necessary to pre-
scribe anti-motion sickness drugs for passengers
receiving meprobamate for other reasons, at least
for relatively short flights,” they said.

In the study, the airmen were given identical
capsules containing either meprobamate, meclizine,
an effective motion sickness preventive, a combina-
tion of these two drugs, or simply sugar about two
hours before a flight in a C-54, the researchers said.
The airmen ranged from 17 to 20 years of age and
had little or no flying experience, they said.

After an hour of straight and level flight, they
said, the airmen were subjected to simulated turbu-
lence, in which the plane pitched and yawed, rolled

and turned, climbed and descended, for 10 to 25
minutes.

Forty-six per cent of the volunteers who had re-
ceived the sugar pills became sick during their
flights compared with 26 per cent of those who took
meprobamate, 25 per cent of those who took mecli-
zine, and 24 per cent of those who received both
drugs, the researchers said.

“Our results indicate that meprobamate affords
significant protection against airsickness equal to
that of meclizine, and that a combination of these
two drugs is not better than either drug alone,” the
researchers said.

The effectiveness of meprobamate is “surprising,”
the authors said. Despite the probable role of psy-
chological factors in motion sickness, they said,
tranquilizers previously tested proved of little value
in preventing the syndrome.

However, they said, there is a distinct difference
between the tranquilizers investigated earlier, all of
which affect the involuntary nervous system, and
meprobamate, which is classified as a muscle relax-
ant and does not affect the involuntary nervous
system.

Since extensive trials during World War II, anti-
histamines have emerged as the most effective drugs
for motion sickness. Meclizine is an antihistamine
and like other antihistamines it also has a tranquil-

( Continued on Page 18)

©bp

PROFESSIONAL LIABILITY INSURANCE

~ rtuz&iuy t&e ctacto* & fisutctice

Professional Protection Exclusively since 1899

jmmgmBBmm • ■ HI 1 1 ■ Hi

SAN FRANCISCO OFFICE: Gordon C. Jones and John K. Galloway, Representatives
1518 Fifth Avenue, San Rafael Telephone 453-5140

Mailing Address: P. O. Box 1079, San Rafael
LOS ANGELES OFFICE: Gilbert G. Curry and Davis S. Spencer, Representatives
Room 109, 101 Vi East Huntington Drive, Arcadia Telephone MUrray 1-5077

Mailing Address: P. O. Box 543, Arcadia

ampe

H ■ 1

T — r-’w"

_____

— _

Advertising • SEPTEMBER 1962

Photographs courtesy of R. H. Grekin, M.D.

Nummular

eczema

Nummular eczema
on the left hand
of a 20-year-old female.

Therapy with
0.25% Neo-Medrol
Acetate, Veriderm
produced this result
in only 5 days.

5 days
later

The topical steroid with the “bonus ’’base

Neo-Medrol Acetate, Veriderm and Medrol Acetate, Veriderm
provide prompt, highly-efficient control of dermatoses. Because
the Veriderm base duplicates the oils found in normal human
skin, there is optimal dispersion of the anti-inflammatory Medrol
content, and the antibiotic, neomycin.

Less greasy than ointment, less drying than lotion, Neo-
Medrol Acetate, Veriderm and Medrol Acetate, Veriderm spread
evenly and merge well with the tissues.

Medrol Acetate, Veriderm is indicated in atopic, contact,
or seborrheic dermatitis, and in neurodermatitis, anogenital
and allergic pruritus. Neo-Medrol Acetate, Veriderm is indi-
cated when dermatoses are complicated by infection. Prompt
control of excessive tissue reaction to allergens, irritants, and
trauma may be anticipated following the topical use of Medrol.

Acetate

The Upjohn Company, Kalamazoo, Michigan

Upjohn

• * *

(Reminder advertisement. Please see package insert for detailed product information.)

Control Constipation
Without Interference

PRULET

A MILD REFLEX
ACTING
LAXATIVE . . .

does not interfere with
other conditions under
treatment.

The active ingredient of
Prulet,® Bis(p-acetoxyphenyl)

-oxindole, is analogous to a
substance found in prunes. Completely recover-
able from the feces, it has no deleterious effect
on the vital organs. It is completely free from
side effects, such as coloring of the urine,
hyperemia and flatulence. During lactation no
portion of the active ingredient of Prulet®
appears in the milk and it has no effect on
the nursing infant.

PRULET

provides therapeutic effectiveness with
milligram dosage.

EASY TO TAKE: Prulet® tablets are small,
odorless, and tasteless.

SUPPLIED: Bottles of 60.

EACH TABLET CONTAINS:

Bis (p-acetoxyphenyl)-oxindole ... 5 mg

DOSAGE: One or two tablets before
retiring until regularity is achieved or as
directed by a physician.

PRECAUTIONS: Presence of nausea,
vomiting, abdominal pains, or other
symptoms of appendicitis.

COMPLETE LITERATURE AND SAMPLES UPON REQUEST

Mission

Pharmacal Co.
SAN ANTONIO 6, TEXAS

Three Scientists Join
A.M.A. Drug Department

Three medical scientists have joined the staff of
the American Medical Association as part of the
A.M.A. ’s expanding program of providing informa-
tion to physicians about drugs and their uses, it was
announced recently.

Named to the post of drug documentation man-
ager was F. R. Whaley, Ph.D., a chemist and special-
ist in the field of technical literature.

Appointed assistant secretaries of the A.M.A.
Council on Drugs were Edward L. Platcow, Ph.D.,
pharmacologist, and Jeffrey Bishop, M.D., a prac-
ticing physician from Vancouver Island, British
Columbia.

Dr. Whaley, a graduate of Northwestern Univer-
sity and of Johns Hopkins University in physical
chemistry, has a long career as an industrial chemist
and a specialist in setting up technical libraries
through use of electronic equipment. He is chair-
man of the chemical literature division of the
American Chemical Society.

Dr. Whaley will supervise the A.M.A.’s new
program of collecting and storing information on
drugs and drug therapy.

Dr. Platcow and Dr. Bishop will study research
data on drugs and drug therapy and prepare reports
for the A.M.A. Journal and New and Nonofficial
Drugs, published annually by the A.M.A.

Dr. Platcow was assistant professor of pharma-
cology at Northeast Louisiana State College. Dr.
Bishop is a graduate of St. Mary’s Hospital of the
University of London, England, and practiced in
London for several years before immigrating to
Canada.

Tranquilizer Prevents
Airsickness

(Continued from Page 15)

izing effect. Its mode of action in preventing motion
sickness has not been determined.

Meprobamate has no antihistaminic effects, but its
tranquilizing effect may be somewhat similar to
meclizine, the researchers said.

“On the other hand,” they said, “the exposure of
individuals with little previous flying experience to
sudden, violent motion of short duration may pro-
vide a situation where tranquilization is uniquely
effective.”

The effectiveness of meprobamate against more
prolonged motion remains to be determined, they
said.

It also would be interesting to study mephenesin,
another muscle relaxant, under similar conditions,
they said, since this drug resembles meprobamate
but has only a slight tranquilizing action.

The authors are affiliated with the Pharmacology/
Biochemistry and Pathology Branches, School of
Aerospace Medicine.

CALIFORNIA MEDICINE

REFERENCES

AND REVIEWS

Increased Activity of Some Folic Acid Enzyme Systems
in Infectious Mononucleosis — J. R. Bertino, B. M.
Simmons, and D. M. Donohue. Blood — Vol. 19:587 (May)
1962.

Glucose 6 phosphate dehydrogenase (G6 PD), and 3
enzymes involved in folic acid metabolism and thus
important for cell replication were studied in the leukocytes
of patients with infectious mononucleosis. C6 PD activity
was less, while the levels of the folic acid enzymes were
increased in infectious mononucleosis leukocytes when com-
pared to normal leukocytes. One enzyme, dihydrofolic re-
ductase, present in the infectious mononucleosis cells, has
not been found in the leukocytes from normal blood. These
findings are similar to the results obtained in acute and
chronic myelocytic leukemia, and indicate that the atypical
lymphocytes seen in infectious mononuclesosis are actively
synthesizing DNA and should be considered immature cells
or virus-infected cells.

* * *

Diagnosis and Treatment of Reversible Hypertension —
T. Winsor, J. P. Medelman, J. H. Moyer, and G. M. Roth.
Dis. Chest — Vol. 41:489 (May) 1962.

The diagnosis of pheochromocytoma is discussed. As
drugs give only temporary relief, all the authors’ patients
are treated surgically. Methods to aid the diagnosis of
occlusive renal artery disease, including percutaneous
femoral arteriograms, translumber aortography, intravenous
aortography, and intravenous pyelography, are reviewed.

The current medical regimen for renal vascular hyperten-
sion is presented.

* * *

Hyperparathyroidism with Avulsion of Three Major

Tendons — F. S. Preston and A. Adicoff. New Engl. J.

Med.— Vol. 266:968 (May 10) 1962.

Hyperparathyroidism in a 33-year-old man presented with
spontaneous avulsion of left triceps and both quadriceps
tendons, and masqueraded as atypical arthritis. A para-
thyroid adenoma was removed and the quadriceps muscle
was repaired. Possible direct effects of excess parathyroid
extract (Para-thor-mone) on connective tissue are discussed.
* * *

Rectal Aminophylline — N. Traverse and M. S. Segal. Ann.

Allergy — Vol. 20:182 (March) 1962.

A concentrated form of aminophylline (100 mg/cc.) ad-
ministered by rectum was evaluated in 206 patients with
bronchial asthma. Plasma theophylline levels were obtained
in 16 patients who received the concentrated aminophylline,
and the levels were found to be significantly higher than
those of the other routes of administration, with the excep-
tion of the intravenous route. The intravenous route showed
initially higher levels of theophylline, but after 2 hours the
level of aminophylline was higher. The rectal route pro-
duced effective clinical results and good patient acceptance.
* * *

Surcical Correction of Total and Partial Anomalous

Pulmonary Venous Connections — P. Zubiate, O.

Magidson, and J. H. Kay. Dis. Chest — Vol. 41:518 (May)

1962.

Ten cases of anomalous pulmonary venous connection
have been operated on and completely corrected without
mortality during the last 2% years. One representative case
(Continued on Page 29)

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CALIFORNIA MEDICINE

REFERENCES AND REVIEWS

(Continued from Page 27)

is presented. Surgical correction under direct vision using
cardiopulmonary bypass permits accurate unhurried correc-
tion of these defects.

* * *

Synergistic Activity of Penicillin and Isoniazid on
Mycobacterium Fortuitum in Vitro — E. M. K. Viachulis
and E. E. Vichner. Dis. Chest — Vol. 41:553 (May) 1962.

Penicillin acts synergistically with isoniazid against
M. fortuitum and concentrations of each drug are thera-
peutically attainable. Synergistic effect was increased as
penicillin concentration increased for a constant isoniazid
concentration. Penicillin acts synergistically with isoniazid
to prevent reduction of the oxidation-reduction indicator
resazurin.

* * *

Culture Tube for the Separation of Anaerobic Bac-
teria— E. M. Stapert, W. N. DeWolff, and W. T. Sokolski.
Amer. J. Clin. Path. — Vol. 37:667 (June) 1962.

The principal features of the new anaerobic culture tube
are a capillary opening at the top of the tube (which limits
the diffusion of oxygen into the fluid thioglycollate medium)
and a protected stopcock at the bottom of the tube (from
which the bottom portion of the culture can be withdrawn).
This tube has been particularly useful in separating anae-
robic bacteria from fast-growing and spreading aerobic
bacteria.

* * *

Method of Filinc Teaching Slides — D. M. Baer. Amer. J.
Clin. Path.— Vol. 37:642 (June) 1962.

Microscope slides with teaching value may be filed in an
ordinary 3 by 5 inch card file using 5 by 8 inch index cards
which have been folded and stapled. Advantages are:

Clinical data are written on the card, cards are inexpensive,
the diagnosis need not be written on the slide, the odd-size
slides are accommodated, and the file is readily expandable.

* * *

Role of Platelet in Fibrinolysis: A Sensitive Test for
Fibrinolytic Activity — W. O. Reid, A. V. Somlyo, A. P.
Somlyo, and R. P. Custer. Amer. J. Clin. Path. — Vol.
37:561 (June) 1962.

A sensitive assay of spontaneous fibrinolytic activity, the
standardized serial thrombin time (STT), is described. Of
40 cases with thrombocytopenia, increased fibrinolysis was
pr. . i In all 20 patients with active bleeding. In non-
hi . : hagic thrombocytopenia, fibrinolysis was normal (11

cases) or decreased (nine cases). Good correlation was
found between STT elevation and severity of bleeding. Post-
mortem fibrinolysis was absent in five cases of severe throm-
bocytopenia. It is suggested that (1) fibrinolysis plays a
major role in thrombocytopenic bleeding, and (2) platelets
contain a plasminogen activator in addition to anti-plasmin.

White Slide Dots: A Time Saving Method — J. W. Gray-
son, Jr. Amer. J. Clin. Path. — Vol. 37:644 (June) 1962.

White ink was substituted for black India ink as a dotting
medium for cytologic and histologic slides. This technique
greatly facilitates the location of areas of interest against
the usual black background of the microscope.

Use of Indicator Calcein, Its Fluorescence, in Rapid
Ultramicrotitration of Serum Calcium — C. S. Klass.
Amer. J. Clin. Path. — Vol. 37:655 (June) 1962.

An ultramicrotechnique for the determination of serum
calcium was developed. Ultraviolet illumination in the 3,660
A. range, an ultramicrotitrator, and the indicator calcein,
(Continued on Page 31)

MORE URINE

INCREASED WEIGHT LOSS

Naturetin has greater diuretic action1-3 than either chlorothiazide or
hydrochlorothiazide. A trial with Naturetin demonstrates the increased
urine volume and the greater weight loss it provides.

1. Ford, R. V.: Clin. Res. Notes 2:1 (Dec.) 1959. 2. Ford, R. V.: Cur. Therap. Res. 2:92 (Mar.) 1960.
3. Elliott, J. P„ Jr., and Goldman, A. M.: South. M.J. 54:794 (July) 1961.

Naturetin —the diuretic with specific difference

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lu>in PineA

NEUROPSYCHIATRIC

HOSPITAL

OPEN, VISITING AND CONSULTING STAFF

BELMONT, CALIFORNIA ESTABLISHED 1925 LYtell 1-8951

In-patient services for acute and chronic
emotional illnesses.

Electric shock Insulin shock

Hydrotherapy Psychotherapy

Occupational therapy

Out-patient services for selective cases

Attending Staff

A. T. VORIS, M.D., Medical Director

DAVID S. WILDER, M.D. • ROBERT E. JAMES, M.D.

ALEXANDER H. MILNE, M.D. • ROBERT L. MEIERS, M.D.

Located 22 miles south of San Fran-
cisco. Accessible to transportation.

Woodside Ams Hospital

Exclusively for the treatment of

ACUTE AND CHRONIC

ALCOHOLISM

MEMBER AMERICAN HOSPITAL ASSOCIATION

1600 Gordon Street • EMerson 8-4134 • Redwood City, California

ALEXANDER SANITARIUM, Inc. located in the foothills of BELMONT, CALIFORNIA

Address Correspondence: MEDICAL DIRECTOR, Alexander Sanitarium, Inc., Belmont. California • LYtell 3-2143

Occupational facilities consist of special occupational therapy
room, tennis court, billiards, badminton court, table tennis and
completely enclosed, heated, full-size swimming pool.

J. M. CRUIKSHANK, M.D., D.P.H., F.A.C.S., Medical Director

PSYCHIATRISTS: JOHN ALDEN, M.D., Chief of Staff; HEN-
DRIE GARTSHORE, M.D., Asst. Chief of Staff; P. P. POLIAK,
M.D., Asst. Chief of Staff; GEORGE KOLAWSKI, M.D.

A patient accepted for treatment may remain under the
supervision of his own physician if he so desires

COMPTON FOUNDATION
HOSPITAL

FORMERLY COMPTON SANITARIUM

820 West Compton Boulevard
COMPTON, CALIFORNIA
NE 6-1185 NE 1-1148

MEMBER OF

American Hospital Association and
National Association of Private Psychiatric Hospitals

High Standards of Psychiatric T reatment
Serving the Los Angeles Area

G. Creswell Burns, M.D.

Medical Director
Helen Rislow Burns, M.D.
Assistant Medical Director

Fully Approved by Central Inspection Board of APA
Accredited by

Joint Commission on Accreditation of Hospitals

CALIFORNIA MEDICINE

New Techniques Spur Study of Brain

Through new techniques of brain exploration,
medical scientists are learning more and more about
human behavior.

Technological developments in medicine, pharma-
cology, and electronics have brought exciting advan-
ces in brain-mapping, according to an article in the
August Today's Health magazine, published by the
American Medical Association.

Tiny electrodes can be pushed deep into the
human brain without damaging its tissues through
holes burred in the skull, it said. Brain tissue has no
feeling, it said, and blunt electrode guides push
nerve fibers aside “like a knitting needle moving
through a ball of loose yarn.”

Scientists with probing electrodes have discovered
and mapped emotional centers deep in the mid-
brain— pinpoints of tissue that control pleasure,
pain, hunger, thirst, sex, and other basic drives,
the article said. By electrically stimulating these
centers in animals and humans, it said, scientists
have produced a gamut of emotional responses and
are learning how these centers color and govern
our behavior — how they remember, how they act
under stress, and how, as a last resort to control
disease, some of these tissues can be destroyed with-
out damaging the rest of the brain.

Neurologists formerly believed that man’s en-
larged cortex, the brain’s outer layer, gave him su-
perior intelligence because it could encompass highly

specialized regions for the control of highly special-
ized activities beyond the capacity of animal brains,
the article continued. They were also convinced that
if the use of one of these regions of the cortex was
lost through injury or disease, the ability it con-
trolled was permanently lost, it said.

However, recent exploration of the brain made
possible by depth electrodes, shows that instead of
strict specialization, the reverse is true, it said.

“Our enlarged cortex permits dispersal of func-
tion control,” the article said. “It provides sheets of
nerve tissue — networks of neurons, or nerve cells — -
in which various regions play some part in many
different activities. True, there are focal centers for
control; but if one section is knocked out or de-
stroyed, another will try to compensate for the loss.

“Thus it is apparent that our cortex, complex and
delicate as it is, has remarkable powers of reorgani-
zation and recovery. Brain surgeons can now op-
erate on areas they formerly feared to touch.”

Also with depth electrodes, brain-mapping scien-
tists are penetrating deeper realms in the mid-brain,
the article continued. Studies have shown that many
emotional centers are densely packed into a layer
of tissue at the core of the brain, known as the
hypothalamus, it said.

“Here are the centers that make us boil with
anger, tremble with fear, bolt in panic, strike out in
rage, melt with love,” it said. “They endow our
world with life and colors and richness.”

(Continued on Page 38)

Approved by the Joint Commission on
Accreditation of Hospitals ; and
The American Psychiatric Association

Occupational therapist guides patient

in newly acquired hobby of making artificial flowers.
All patients at Camelback Hospital are encouraged to participate
in constructive hobbies as another integral part ol their

rehabilitation program, according to doctor’s instructions.
Hobbies may be pursued outdoors in the scenic recreation

area or in the special hobby workshop in the hospital.

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CALIFORNIA MEDICINE

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years of control

eye ailment, his need for
Orinase increased again. During
his wife’s convalescence, he
was taking 2.5 Gm. daily.

The patient’s dosage had to be
increased in 1960 at the death of
his sister (also a diabetic).

For two months, maintenance of
control required 2.5 to 3.5 Gm.
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then leveled off again at 1 Gm.

irinase* (tolbutamide) stands in a unique position; it alone,
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ment. Patient data, made available to us by physicians, have

been factually incorporated; however, patients’ identities

have been concealed. Any inquiries regarding this Orinase

case history series should be addressed to: Medical
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Orinase is supplied in bottles of 50 and 200 tablets.
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New Techniques Spur Study of Brain

(Continued from Page 33)

Research efforts in this area have bold objectives:
to control the basic drives in humans, to correct
imbalances that result in mental and emotional dis-
orders and in all kinds of psychosomatic disease,
the article pointed out.

“Depth electrodes are a priceless tool,” it con-
cluded. “They stir up and agitate nerve cells,
thoughts, and feelings, and may restore disturbed
mental and emotional balances, and give researchers
an essential checking procedure for the analysis of
drug effects.

“With their new techniques and knowledge of the
brain, scientists are already able to help victims of
nervous and mental disorders they could never help
before. They stand on the brink of discoveries that
may reveal some of the deepest secrets of the human
mind and emotions.”

The article was written by Robert O’Brien.

Late Look at Safety of Aspiration Biopsy — J. W. Berg

and G. F. Robbins, Cancer, 15:826 (July-Aug.) 1962.

A previously reported study of aspiration biopsy of breast
cancer was brought up to date, and new methods of com-
parison were tried to see if aspiration prejudiced the pa-
tient’s later course. The only differences in prognosis elicited
by the various methods favored rather than discouraged
aspiration. There is no reason to consider this procedure
detrimental to the patient.

COOK COUNTY

graduate school of medicine

CONTINUING EDUCATION COURSES
STARTING DATES— FALL. 1962

Surgical Technic Two Weeks, Nov. 5

Surgery of Colon & Rectum One Week, Nov. 26

Surgery of Stomach & Duodenum .One Week, Sept. 24

Vaginal Approach to Pelvic Surgery One Week, Oct 1

Gynecology, Office & Operative Two Weeks, Nov. 5

Obstetrics, General & Surgical . ..Two Weeks, Oct. 8

Urology Two Weeks, Oct. 29

Proctoscopy & Sigmoidoscopy One Week, Oct. 29

General Practice Review One Week, Oct. 8

Gallbladder Surgery 3 Days, Oct. 8

Surgery of Hernia 3 Days, Oct. 11

Basic Electrocardiography One Week, Oct. 1

Advances in Medicine One Week, Oct. 15

Advances in Surgery One Week, Dec. 10

Blood Vessel Surgery One Week, Oct. 22

Board of Surgery Review, Part I Two Weeks, Nov. 5

Board of Surgery Review, Part II Two Weeks, Nov. 26

Clinical Uses of Radioisotopes Two Weeks, Oct. 1

Treatment of Varicose Veins One Week, Oct. 29

Information concerning numerous other continuation courses
available upon request.

TEACHING FACULTY:

Attending Staff of Cook County Hospital

ADDRESS:

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Chicago 12, Illinois

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A.M.A. Council Takes Stand
On Fat in the Diet

The American Medical Association, through its
Council on Foods and Nutrition, recently approved
the concept of modifying the type and amount of
fat in the diet as an experimental means of treating
hardening of the arteries.

A council report, appearing in the August 4
Journal of the American Medical Association, is the
A.M.A.’s first official statement on the controversial
cholesterol question and culminates a three and one-
half year study.

The report was not a recommendation for the
general public. It was directed exclusively to physi-
cians as a guide in treating patients.

A direct causal relationship between diet or blood
fat concentrations and hardening of the arteries has
not been proved, the council said, but added :

“In the light of present knowledge, it appears
logical to attempt to reduce high concentrations of
cholesterol and other serum lipids [fats in the
blood] as an experimental therapeutic procedure.”

Indications for modifying dietary fat are hyper-
cholesteremia and hypertriglyceridemia, both of
which have been “associated with” hardening of the
arteries, the council said. The terms define condi-
tions in which cholesterol or triglyceride, both fats,
are present in the blood in abnormally high con-
centrations, it said.

Regulation of dietary fat produces “marked ef-
fects” upon hypercholesteremia, the council said.
Studies have established, at least in experimental
conditions, that substitution of polyunsaturated
vegetable oils for animal fats and saturated vege-
table fats in the diet of man resulted in a reduction
of blood cholesterol, it said.

The mechanisms by which polyunsaturated fatty
acids lower blood cholesterol, however, are “poorly
understood,” it said.

The properties of fats are related generally to the
fatty acids they contain, it was explained in the
report. Fatty acids are classified as either saturated
or unsaturated on the basis of their chemical struc-
ture. A saturated fatty acid contains all the hydro-
gen atoms it can hold while the polyunsaturates
contain more than one unsaturated bond in their
chemical linkage and a monounsaturated fatty acid
has only one unsaturated bond.

“Actually, the terms ‘animal’ and ‘vegetable’ do
not distinguish between fats which raise and those
which lower serum lipid levels,” the council said.
“Both butter and coconut oil can be shown to raise
serum cholesterol, whereas corn oil and whale oil
can lower it.”

The terms “saturated” and “unsaturated” also are
unsuitable for distinguishing fats which raise or
lower fat concentrations, it said, “since neither all
saturated fatty acids nor all unsaturated fatty acids

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are identical in their effects upon serum cholesterol
concentrations in man.”

Increasing interest in control of hypercholester-
emia by regulation of dietary fat has developed be-
cause of evidence suggesting that serum cholesterol
concentrations are related to hardening of the ar-
teries, the council said. The amount and kind of
dietary fat are among the most important factors
controlling fat concentrations in the blood, it said.
Statistical studies suggest that a relationship between
diet, blood cholesterol and the rate of coronary
artery disease exists in various populations, it said.

Many studies also have indicated a “close asso-
ciation” between elevation of blood triglyceride
concentration and coronary artery disease, the coun-
cil said. The cause of fat-induced hypertriglyceride-
mia has not been determined, it said, but some
investigators have proposed that it is “probably a
rare familial disorder.”

The treatment of hypercholesteremia with a low-
fat diet is “not effective,” the council said. The effect
of simply reducing fat intake is to lower blood
cholesterol concentration but raise blood triglyceride
concentration, it said.

“Increasing the ratio of polyunsaturated fat to
saturated fat in the diet is the preferred method for
treating the ‘usual’ hypercholesteremia,” the council
said.

Alteration of dietary fat is usually not necessary

in the treatment of obesity on the basis of current
scientific evidence, the council added.

The basic cause of obesity is an intake of calories
in excess of what the body needs, the report said.
Treatment consists of reducing total caloric intake,
it said.

The report, entitled “The Regulation of Dietary
Fat,” also discusses the chemistry and metabolism of
fats and other disease situations in which fat modi-
fication is indicated.

It was prepared by the ad hoc Committee on
Dietary Fat Levels of the council. Members of the
committee are David B. Hand, Ph.D., Geneva, N. Y.,
chairman; Elizabeth K. Caso, D.P.H., Boston; Wil-
liam J. Darby, M.D., Nashville, Tenn.; Charles S.
Davidson, M.D., Boston; Paul L. Day, Ph.D.,
Bethesda, Md.; George V. Mann, M.D., Nashville,
Tenn.; Robert E. Olson, M.D., Pittsburgh, and
Philip L. White, Sc.D., director of A.M.A.’s depart-
ment of foods and nutrition, Chicago.

Prognosis of Henoch-Schonlein Nephritis — F. B. Rob-
erts, R. J. Slater, and B. Laski, Canad. Med. Assn., 87:49
(July 14) 1962.

Only 2 of 50 children were found to have abnormal Addis
counts 6 months to 8 years after having had anaphylactoid
purpura. Also 23 of 35 patients with Henoch-Schonlein ne-
phritis underwent remission while being followed. These
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Diagno

^ O' M E D I C I N E

OFFICIAL JOURNAL OF THE CALIFORNIA MEDICAL ASSOCIATION
© 1 962, by the California Medical Association

Volume 97 SEPTEMBER 1962 Number 3

The Newer Penicillins

HAROLD J. SIMON, M.D., Ph.D., Palo Alto

• The newer penicillins give high promise of
overcoming some of the few disadvantages of
penicillin-G.

They fall into three groups: The alpha-
phenoxy-penicillins ; the penicillinase resistant
penicillins ; and the penicillins with enhanced
activity against gram-negative bacteria.

The newer alpha-phenoxy-penicillins offer
little over alpha-phenoxy methyl penicillin (pen-
icillin-V). As the length of the side chain is
increased, absorption and attainable serum con-
centration is also increased, but these are
questionable benefits and probably not signifi-
cant for therapeusis.

The penicillinase-resistant penicillins have
once more brought almost all severe staphylo-
coccal infections within therapeutic range.
One of them, methicillin, must be administered

parenterally. It is the agent of choice for the
treatment of severe, penicillin-G resistant staphy-
lococcal infections, and this is its only clinical
indication. Another, oxacillin, which may be ad-
ministered orally, is partially resistant to gastric
acid degradation, but must be given on an
empty stomach. It is most useful as prolonged
therapy following methicillin, in the treatment
of mixed hemolytic streptococcal-penicillin-G re-
sistant staphylococcal infections, and as primary
therapy for moderately severe penicillin-G re-
sistant staphylococcal infections.

The third group is still mostly in the experi-
mental stage, but some strains of Proteus, E.
coli, Salmonella and Shigella are highly vulner-
able to their action.

Toxic and allergic reactions to the newer pen-
icillins, and crossed allergic reactions with peni-
cillin-G, present unsolved problems.

Penicillin is a most interesting compound. It was
the first of the truly effective antimicrobial com-
pounds to be discovered and widely used. It is
clearly the most effective agent available against
susceptible bacteria. It is almost completely non-
toxic. Consequently, there is a great deal of en-
thusiasm today because of the promise that newer

From the Department of Medicine, Division of Infectious Diseases,
Stanford University School of Medicine, Palo Alto.

This investigation was supported in part by a research grant
(E-3371) from the National Institute of Allergy and Infectious Dis-
eases, National Institutes of Health, United States Public Health
Service.

The methicillin (as Staphcillin® ) , oxacillin (as Prostaphlin®) ,
and P-50 used in these studies was supplied through the courtesy of
Drs. John Doyle and Eugene Morigi, Bristol Laboratories, Syracuse,
New York.

Modified from an address, "Spotlight on Medicine,” presented be-
fore a General Meeting at the 91st Annual Session of the California
Medical Association, San Francisco, April 15 to 18, 1962.

penicillins may be at hand to overcome some of the
deficiencies of the parent compound.

Penicillin-G (Potassium)

PROSTHETIC croup* - acylation 6 Ami nopeni ci Manic Acid^
[Benzyl] [6 APA]

‘Specific Antibacterial
Activity Resides Here

^Allergenicity Resides Here

All penicillins contain 6 APA

Chart 1. — Structural analysis of penicillin-G potassium.

VOL. 97, NO. 3

SEPTEMBER 1962

135

Before exploring some of the more important as-
pects of the newer penicillins, however, a guiding
principle for antimicrobial therapy deserves to be
stated clearly. No antimicrobial agent so far dis-
covered or devised can compare with penicillin-G
for effectiveness, economy, and safety. Moreover,
many physicians using penicillin-G still find it diffi-
cult to apply generally available information on
dosage, preparation, and route of administration to
common clinical problems. It is therefore mandatory
that the following remarks be interpreted in view
of three basic principles :

First: The etiological agent in any disease process
should be identified at all costs and its susceptibility
to penicillin-G ascertained, preferably before ther-
apy is begun, unless an urgent situation demands
immediate action. The emphasis is on the word
urgent. Such situations are rare in practice.

Second: Penicillin-G should be used whenever
possible, and this usage should follow the principles
developed over the past 20 years of experience with
this agent.

Third : The newer penicillins should be ap-
proached with caution on several counts. Experience
with these agents is limited, and the historical per-
spective for rational evaluation of the new agents is
not yet available. Also, it is already established that
the newer penicillins differ pharmacologically from
penicillin-G. Absorption, distribution, and excretion
data are still incomplete. However, some of these
agents are excreted through the biliary system in
significant amounts. With differences in their phar-
macologic structure may come differences in tox-
icity. In addition, there are definite and significant
differences in antibacterial activity between the
various penicillins. Some of the newer penicillins
were specifically devised to take advantage of such
differences. Nevertheless, it has already been con-
clusively demonstrated that none of the newer homo-
logues matches penicillin-G for anti-streptococcal or
anti-pneumococcal activity. The use of the newer
penicillins in such infections, already open to ques-
tion on the basis of lesser activity than penicillin-G,
must be carefully weighed. Differences in efficiency
must be taken into account for calculation of dos-
ages, time-schedules and routes of administration.
Finally, sight must not be lost of the fact that the
newer penicillins are more costly than penicillin-G
by several orders of magnitude.

Nevertheless, even penicillin is still far from
being the perfect antibacterial agent. Patients tend
to develop allergic sensitivity to penicillin, and
some of the reactions are extremely serious. More-
over, bacteria seem to learn chemistry fairly easily.
Several bacterial species can produce enzymes, peni-
cillinase and penicillin acylase, which destroy

penicillin-G and some of its homologues. In addi-
tion, its activity against Gram-negative bacilli leaves
much to be desired. Consequently, there are really
four spheres in which research on the structure of
penicillin homologues could offer significant con-
tributions:

The development of a penicillinase-resistant peni-
cillin molecule presented the most urgent problem.
This seems now to have been solved. Methicillin
(Staphcillin®) , oxacillin (Prostaphlin®) and other
semisynthetic penicillins have been developed by
several pharmaceutical houses and are now available
or are in the last phases of clinical trial.

Penicillins are needed to which patients do not
manifest allergic sensitivity or allergic cross-sen-
sitivity to other homologues. The prospect for a
break-through in this direction seems very remote.
The allergenic potential of the penicillins seems to
reside in a very small fraction of the basic 6-amino-
penicillanic acid (6-APA) molecule. This fraction
seems to act as a hapten with serum or tissue protein
to become a complete antigen. Penicillin residues
without 6-APA are no longer active against bacteria.
Penicillinase destroys the antibacterial activity but
leaves the allergenic fraction intact. Penicillinase
therefore has no place in clinical therapy. Probably
every penicillin homologue will carry the risk of
hypersensitization with it.

The problem of allergic cross-sensitivity between
the penicillins is still under discussion. Most inves-
tigators believe allergic cross-sensitivity to be com-
plete. The difficulty of eliciting clear histories of
penicillin reactions in the absence of complicating
factors, and the probable loss of reactivity over
prolonged periods of time, make any attempt at
sharp definition of allergic cross-sensitivity ex-
tremely difficult. A high proportion of patients claim
penicillin allergy. Yet penicillin is present in milk,
in vaccines and in the environment. Consequently,
the true incidence of enduring penicillin allergy
must be considerably smaller than is generally
claimed, although transient hypersensitivity may
occur frequently. Allergic reactions to the newer
penicillins have already occurred and appear identi-
cal with those attributed to penicillin-G. A few
instances of reactions to the newer penicillins have
also been reported in patients whose past history
of allergic sensitivity to penicillin seemed well de-
fined. On the other hand, some patients with a
history of reaction to penicillin-G have tolerated the
newer penicillins. The problem of allergic cross-
sensitivity is therefore not yet solved, and the pros-
pects for solution seem remote.

The third problem concerns the administration of
these agents. The oral route is always safer and
usually more convenient than the parenteral route.

136

CALIFORNIA MEDICINE

6 Aminopenici Manic Acid

i R '

Determines
absorption
and spectrum

-C-

/3-lactam Thiazo I i d i ne
ring ring

-C-

l/S\r/CH3
|"CH3

!</*

-N-

— C-

Very labile

(Penicillinase acts here)

-C-

-H

Na
K

Al . . .....

Procaine) solubility

salts

determine

Chart 2. — -Chemical formula of 6-amino-penicillanic acid and its relation to various side chains.

Consequently, penicillins are needed which over-
come some of the defects of penicillin-G, can be
administered by mouth at convenient intervals, and
are quantitatively absorbed. The prospects are fairly
bright. The whole group of phenoxy-penicillins —
methyl, ethyl, and propyl — can be administered
orally. They resist gastric digestion fairly well and
are readily absorbed. The phenoxy-penicillins are
destroyed by penicillinase. Oxacillin resists penicil-
linase-degradation and is absorbed following oral
administration.

A fourth problem concerns the rather limited
spectrum of the penicillins. Many physicians think
of penicillin-G as being highly and exclusively effec-
tive against the Gram-positive cocci — pneumococcus,
streptococcus, meningococcus, and some staphylo-
cocci. Penicillin-G, however, does possess significant
activity against a variety of Gram-negative bacilli,
although much higher doses must be employed to
attain significant clinical effects. It seems desirable,
therefore, to find a penicillin with decidedly en-
hanced anti-gram-negative bacillary activity. Several
penicillin homologues with this characteristic have
been synthesized and are now undergoing clinical
trials. To date, however, they are still quite feeble.
They are also susceptible to penicillinase. Moreover,
severe diarrhea and monilial superinfection have
already occurred. These are very similar to those
occurring after tetracycline therapy. The broad-
spectrum penicillins therefore seem to possess the
antibacterial spectrum of the tetracyclines, only they
are bactericidal where tetracyclines are bacterio-
static. These penicillins seem also to combine the
advantages and hazards of penicillin therapy with
the advantages and hazards of tetracycline therapy.
In short, these broad-spectrum penicillins still leave
a great deal of room for improvement.

6 Aminopenicillonic Acid

yfl-lactom Thiazolidine

Chart 3. — The chemical formulae of the prosthetic
groups of the phenoxy-penicillins.

In order to understand something of the back-
ground and possible future of the newer penicillins,
it seems desirable to digress for a moment into
chemistry. The penicillin molecule was found to
consist of three functional elements: The basic
nucleus common to all penicillins is called 6-amino-
penicillanic acid, or 6-APA. One part of this seg-
ment is a beta-lactam ring, the site of penicillinase
action. By itself, 6-APA has no antibacterial activity.
Nevertheless, the side chains which determine anti-
bacterial activity and absorption are devoid of anti-
bacterial activity unless coupled to 6-APA. It is

VOL.. 97, NO. 3 • SEPTEMBER 1962

137

these side chains that are being substituted to make
the newer penicillins. The third component is one
of several cations which chiefly determines solubility.

The three phenoxy-penicillins — methyl, ethyl, and
propyl — offer several advantages over penicillin-G.
They are readily absorbed when taken by mouth.
They are at least partially resistant to gastric acid
degradation. Serum concentrations following oral
administration may briefly approximate concentra-
tions achieved following the parenteral administra-
tion of penicillin-G. It is not clear whether this is
reflected in tissue concentrations, however. The
three phenoxy-penicillins differ from one another in
the fact that, following the same dose, peak serum
concentrations are achieved earlier and range higher
as the length of the side chain is increased from
methyl through ethyl to propyl. Unfortunately, ex-
cretion is also more rapid in direct relationship to
the length of the side chain. Consequently, high
serum concentrations are maintained for a shorter
time between doses. The importance of this “time
under the curve” in serum is not clear. It is not
known whether sustained antibacterial serum con-
centrations are required for the control of infections,
or whether intermittent peak concentrations are
desirable. The chances are that both may be im-
portant in diverse clinical conditions. Since tissue
concentrations persist longer and fluctuate less, the
emphasis on serum concentrations is probably mis-
placed anyway. Moreover, it is very likely that
tissue concentrations are more important than serum
concentrations. These pharmacological data should
be remembered when the phenoxy-penicillins are
employed.

The antibacterial spectrum of the phenoxy-peni-
cillins does not differ significantly from that of
penicillin-G, although most susceptible strains re-
quire greater concentrations of the phenoxy-peni-
cillins for inhibition. The differences are slight, and
the dosages usually recommended make up for these
disparities.

The disadvantages of the phenoxy-penicillins lie
in their cost, which is much greater than for peni-
cillin-G, and in their susceptibility to penicillinase.
They are somewhat more resistant to this enzyme
than is penicillin-G, but the differences are probably
of no clinical significance. Patients with allergic
sensitivity to penicillin-G should be presumed sensi-
tive to these newer agents also. To date, there have
been no new toxic reactions reported for this group
of compounds.

The most exciting aspect of the phenoxy-penicil-
lins is not their antibacterial activity; it is the fact
that these agents represent an almost immediate
application of basic chemical research to clinical
medicine. Less than three years have elapsed since

6 Aminopenicillonic Acid

^-lactom Thiazolidine
ring ring

obsorption
ond spectrum

-L — L I

'^CH,

-0-

-H

salts

determine

solubility

SOME IMPORTANT PENICILLINS

(r)

Prosthetic Groupv~-^

Nome(s)

Route of
Administration

Penici llinase

Spectrum

OcH2~

Benzyl-
penicillin
Penicillin G

Oral,

intramuscular,

intravenous

susceptible

Grom positive cocci
High doses for some
Proteus. Solmonella

x:h3

Methicillin

(r)

Stophcillinw

Intramuscular,

intravenous

resistant

Penicil lin-
resistant
staphylococci

Oo-

n(/SChj

P-12

Prostaphlin^

Oxacillin

Oral,

intramuscular

resistont

Penicillin-resistant

staphylococci

other gram positive
cocci

<c==y~ i”2-

' »NH3

P-50 ^
Penbritin^

Oral,

intramuscular

susceptible

E. coli, Salmonella,
Shigella, some
Proteus, Grom positive
cocci

Chart 4. — Structural and functional analysis of the peni-
cillin molecule and some of its more important homo-
logues. (Modified from Dowling, H. F., C. Clin. Pharm.
Therap., 1961, 2:573, with kind permission of C. Y. Mosby
Co.)

the isolation of 6-APA. These newer penicillins
already have been available for over two years.
Even at the time of this writing, a new compound,
alpha-phenoxy-benzyl penicillin (Penspec®), is mak-
ing its appearance in England. It seems to promise
still greater achievements in the phenoxy-penicillin
range, but experience is severely limited. The syn-
thesis of these compounds opened an entirely new
field, and the next substance truly represents a
breakthrough for clinical medicine.

Methicillin, 2,6 dimethoxyphenyl-penicillin,
(Staphcillin®) , was the first of the new penicillins
to possess essentially complete resistance to penicil-
linase. Essentially all clinically important instances
of penicillin-resistant staphylococcal infections are
due to penicillinase elaboration on the part of the
infecting micro-organisms. Consequently, physicians
confronted with penicillin-resistant staphylococcal
infections have been given a new and potent weapon.
Enthusiasm was limited initially by an apprehen-
sion that the experimental results might not be
fulfilled in actual practice. These doubts are now
dispelled.

Methicillin is highly effective against all but ap-
proximately 1 per cent of penicillin-resistant staphy-
lococci. Almost overnight, multiple antimicrobial
regimens have become obsolete. Vancomycin, the
agent upon which we had to rely previously for
bactericidal anti-staphylococcal activity in penicillin-

138

CALIFORNIA MEDICINE

resistant infections, is now relegated to a minor
supporting role. Methicillin is the agent of choice
for all serious staphylococcal infections unless aller-
gic sensitivity precludes its use. Experience to date
already indicates that methicillin, properly used,
once again restores the effectiveness of anti-staphy-
lococcal therapy to the high level experienced when
penicillin-G first became available. It must be re-
membered that mortality from staphylococcal in-
fections in the middle and latter 1950’s was not
significantly less than it had been before the intro-
duction of penicillin-G. The key, however, lies in
the phrase properly used.

Methicillin must be administered parenterally.
The preferred route is by means of intermittent
intramuscular or intravenous injections. One gram
every three to four hours is the recommended adult
dose. Intravenous injections may be made directly
into the vein, or into the tubing of a continuous
infusion of saline or dextrose in water. On certain
occasions, however, it may become necessary to use
a continuous infusion of methicillin. This requires
precautionary measures.

Solutions of methicillin are quite unstable. Ini-
tially, dosages of 6 to 8 grams of methicillin given
intramuscularly or intravenously in divided doses
or by continuous infusion, seemed to be satisfactory
on the basis of experimental and clinical data until
several treatment failures occurred. Even now, some
physicians order dosages of 12 to 20 grams daily.
Since severe staphylococcal infections usually re-
quire several weeks of sustained therapy, and the
drug is very expensive, this development seemed to
threaten the widespread use of methicillin. At least
some of this confusion is due to inactivation of
methicillin in the infusion bottle.

It is not generally appreciated that the pH of
normal saline solution is usually close to 6.0, and
the pH of 5 per cent dextrose in water may range
to 4.5, depending on the amount of gluconic acid
formed during sterilization or on the shelf after
exposure to light or heat. Methicillin is highly un-
stable at acid pH and is readily inactivated unless
infusions are buffered. I generally use sodium bi-
carbonate in amounts sufficient to turn pH test
paper strips to pH 7.2 to 7.4. Generally, 20 to 25 ml.
(18 to 23 mEq.) per liter of infusion suffice for this
purpose. This seems cumbersome. Nevertheless, it
seems the only way to administer this agent by
means of continuous infusion without excessive in-
activation. Additionally, the solutions should not be
made up until immediately before use. Even though
alkalinization is carried out, the infusion should be
changed at least every eight hours. Unless these
directions are followed, higher dosages are neces-
sary, with greater expense to the patient.

TABLE 1. — Administration of Methicillin

Intramuscularly: 1 gram every three or four hours.
Intravenously: 1 gram every three to four hours directly
into the vein or into the tubing of a continuous infusion.
Intravenously:* At least 6 to 8 grams per day by con-
tinuous infusion.

Indications: Only for penicillin-G resistant staphylococcal
infections in patients not known to have allergic sensi-
tivity to penicillin-G.

•CAUTION: Alkalinize infusions to pH 7.2 to 7.4. Change infu-
sions every eight hours. Do not add other drugs to infusion.

Intramuscular administration is generally safe and
reasonably well tolerated. However, patients with
bleeding tendencies do not tolerate the intramuscular
route well. Patients with diabetes mellitus, patients
in shock and those with other circulatory disorders
may not absorb the drug from intramuscular depots.
Intravenous administration then becomes the method
of choice.

One other note of caution is indicated. The la-
bility and chemical reactivity of methicillin make
it unwise to use vitamins or other drugs in the same
infusion.

Methicillin has three disadvantages: It must be
given parenterally; it is either completely degraded
or not absorbed from the intestinal tract; it pos-
sesses only feeble activity against bacteria other
than penicillin-resistant staphylococci. Moreover,
allergic sensitivity to penicillin probably means sen-
sitivity to methicillin also. Consequently, the only
indication for methicillin seems to be penicillin-G
resistant staphylococcal infections occurring in pa-
tients not allergic to penicillin. Methicillin is ex-
pensive and unstable. Therefore, while an extremely
useful addition to the anti-staphylococcal armamen-
tarium, it still leaves much to be desired.

Methicillin is primarily cleared through the kid-
neys. Very little appears in the bile. Evidence of
renal impairment has already been reported in a
few patients to whom methicillin was being admin-
istered. One case of bone marrow depression has
recently been reported, and I have seen another in
which this condition was attributed to methicillin.
There may be other as yet undiscovered toxic haz-
ards. As with all new drugs, continuous vigilance is
the only safeguard we can offer our patients.

More recently, a group of semisynthetic penicillins
has appeared whose chief virtue overcomes one of
the serious defects of methicillin. This group, of
which oxacillin (Prostaphlin®) is the prototype,
combines penicillinase-resistance with adequacy of
absorption following oral administration. Milligram
for milligram, these agents are more effective than
methicillin. This greater activity extends across the
penicillin-G-resistant staphylococci to the other
Gram-positive cocci but still does not equal the

VOL. 97. NO. 3 • SEPTEMBER 1962

139

activity of penicillin-G against these micro-organ-
isms. Experience with this newer penicillin has been
almost completely limited to use of the drug by
mouth, although parenteral forms are being tested.
It has already become clear that severe staphylococ-
cal infections can be treated with oxacillin therapy
alone, although this is not yet recommended. The
intelligent use of these agents also requires some
understanding of their pharmacological properties.

Oxacillin is subject to degradation by gastric acid
and must be administered on an empty stomach. In
addition, serum concentrations are not well main-
tained. Dosages should therefore not be spaced more
than four hours apart — at least for serious infections
and until more data become available on tissue
concentrations. In general, we recommend doses of
100 mg. by mouth per kilogram per day in divided
doses at four-hour intervals spaced around meals.
Administration should take place no less than one
hour before nor sooner than two hours after meals.
(If daytime meals fall at 8 a.m., 12 noon, and 7
p.m., the dose sequence runs something like this:
7 a.m.. 11 a.m., 3 p.m., 6 p.m., 10 p.m., 2 a.m.)
Effective serum concentrations are maintained for
slightly more than two of the four hours. If admin-
istration coincides with a meal, however, essentially
no activity is detectable in the serum.

The precise role of the oxacillin group of peni-
cillins is still difficult to assess. Experience is still
too limited and the use of these antibiotics as first
line agents in the treatment of severe staphylococcal
infections — while probably appropriate — cannot yet
be recommended. Three spheres of usefulness can
now be defined, however:

1. Their main use lies in the prolonged treatment
of severe, penicillin-resistant staphylococcal infec-
tions after parenteral methicillin therapy has allowed
some stabilization of the clinical situation.

2. Moderately severe infections — osteomyelitis,
progressive cellulitis and pyelonephritis, for example
— can be treated with oral administration of oxacil-
lin alone, always provided that careful follow-up
cultures and clinical observation are carried out and
care is taken not to interfere with absorption.

3. These agents are also most useful for the treat-
ment of mixed hemolytic streptococcal-staphylococ-
cal infections when the staphylococcal component is
penicillin-G-resistant. Examples include atopic ecze-
ma, impetigo and streptococcal pharyngitis. Despite
the clearly penicillin-G-susceptible nature of Group
A hemolytic streptococci, penicillin-G may fail when
penicillinase-producing staphylococci share the in-
fected sites. Such failures are presumed due to local
inactivation of penicillin-G by the penicillinase that
is produced. The small amounts of penicillin usually
used in such infections are inadequate to overcome

TABLE 2. — Administration of Oxacillin

Orally: 100 mg. per kilogram of body weight per day di-
vided into four-hourly doses and spaced around meals.*
Intramuscularly : 50 mg. per kilogram of body weight per
day divided into four-hourly doses.f

•CAUTION: For oral use, administer on an empty stomach. Oral
therapy administered no less than one hour before meals nor sooner
than two hours after meals.

tOxacillin not yet available for parenteral administration.

this form of biological antagonism. Oxacillin and its
congeners are definitely indicated in such situations
and have proven highly satisfactory.

Unfortunately, allergic reactions have already
been observed, and allergic cross-sensitivity can be
expected in patients who are sensitive to penicillin-
G. Diarrhea, epigastric pain, nausea, and bitter taste
occur commonly at the doses recommended. Some
instances of increases in serum glutamic oxaloacetic
transaminase (SGOT) activity have been reported.
The elevated SGOT reverted to normal when the
drug was discontinued. These drugs are also much
more expensive than penicillin-G. Nevertheless, they
promise to be very useful.

Other developments in the penicillin series seem
potentially to have even greater promise for the
future. Penicillin-G has been known for its activity
against some strains of Proteus, E. coli, and Sal-
monella. Most of these anti-gram-negative bacillary
activities are more striking in the test tube than on
clinical application. Very recently a new penicillin
has been synthesized in which the anti-gram-nega-
tive bacillary activity of penicillin-G has been en-
hanced. The importance of this development cannot
be overemphasized in view of the progressive in-
crease and severity of such infections occurring in
hospitals.

The prototype of this group is alpha-aminobenzyl-
penicillin, (Penbritin®) , or P-50. P-50 retains most
of the anti-gram-positive coccal activity of penicil-
lin-G. In addition, however, it is significantly more
effective than penicillin-G against many strains of
Proteus, most strains of Salmonella and Shigella,
E. coli and Klebsiella-Aerobacter. P-50 is useless
against other strains of Proteus and Pseudomonas.
It is destroyed by penicillinase. P-50 therefore com-
bines the bactericidal properties of penicillin-G with
the broad spectrum coverage of tetracycline. Unfor-
tunately, P-50 does not come as an unmixed
blessing.

Clinical experiences are still meager. Nevertheless,
typical penicillin rashes are already attributed to
P-50. Their incidence cannot be evaluated thus far,
but seem no less than with penicillin-G. Fulminant
diarrhea and moniliasis have also been encountered.
Consequently, while P-50 seems to combine the
beneficial attributes of penicillin-G and tetracycline,

140

CALIFORNIA MEDICINE

it also adds their major side effects. Moreover,
swelling of the mouth and lips has been seen in
experimental animals, but not yet in human beings.
This completely new reaction once again emphasizes
the potentiality for new reactions inherent in all
new drugs no matter what their genealogy.

Dosage schedules are not fully established. This
agent is still in short supply and will undoubtedly be
very expensive. Nonetheless, it is the first of what
promises to be a most interesting and useful series
of penicillins. Their chief virtues will lie in their
anti-gram-negative bacillary activity. Several other
preparations are now undergoing clinical trials, but
none is as close to P-50 with respect to clinical
applicability.

Pharmacologically, the newer penicillins differ
from penicillin-G in at least one major category.
They are all more or less excreted in the bile. Renal
excretion is less prominent, and new pharmacologi-
cal possibilities are presented.

Biliary excretion of active drug might lead to
internal recirculation and cumulation. Hepatic dys-
function, never of consequence with penicillin-G,
might seriously affect the clearance of the newer
compounds. The need for hepatic participation in
their metabolism sets the stage for potential hepatic
and other toxicities. These considerations must be
weighed when the new penicillins are used.

The smaller fraction of renal excretion also in-
fluences one other aspect of penicillin therapy.
Probenecid (Benemid®) blocks the renal clearance
of penicillin-G. The addition of probenecid to peni-
cillin-G therapy increases both the peak concentra-
tions attained and the duration of penicillin-G
persistence in body fluids. Interestingly, probenecid
also increases and prolongs significantly the serum
concentrations of the newer penicillins. This prop-
erty might be used to make smaller doses stretch
further. In general, however, the use of probenecid
cannot be recommended. It is a sulfonamide deriva-

tive and hypersensitivity reactions are not uncom-
mon. Added to those associated with penicillin, these
reactions would raise the risk of side effects to high
orders of probability. Besides, as was previously
noted, the significance of high or sustained serum
concentrations is still unknown.

The vital question of bacterial resistance to the
penicillinase-resistant penicillins cannot yet be an-
swered fully. Very few methicillin-resistant coagulase
positive staphylococci have been recovered from
treated patients. Coagulase-negative staphylococci,
on the other hand, have developed very high orders
of resistance in vitro and in vivo. Coagulase-positive
staphylococci have been rendered partially resistant
to methicillin in vitro, but seem to lose some of their
virulence in the process. Unfortunately, resistance
to methicillin seems to cross with resistance to the
other penicillinase-resistant agents. The resistant
strains do not destroy the newer penicillins, but seem
instead to become drug-indifferent. On the basis of
this evidence, therefore, methicillin and allied re-
sistance problems may once again rise to plague
physicians.

Since methicillin is used almost exclusively in
hospitals, it was anticipated that the appearance of
resistant strains would occur first and be chiefly
limited to hospital settings. Restriction of this drug
was therefore rational. The development of oxacillin
and its congeners and the cross-resistance problem
between these and methicillin casts a new light on
the problem. It is likely that many ambulant pa-
tients will be treated inadequately. Resistant strains
may therefore appear and accumulate in the com-
munity as well as in the hospital. This would du-
plicate past experiences with other antimicrobial
agents. Consequently, it becomes vitally important
to use these potent, valuable agents only on specific
indication, in effective doses and for long enough
periods in order to minimize the emergence of re-
sistant bacterial strains.

300 Pasteur Drive, Palo Alto.

£ >

• .[ r ,

mmkz

VOL. 97, NO. 3 • SEPTEMBER 1962

141

Standards of Therapy for Tuberculosis, 1962

W. H. OATWAY, JR., M.D. and DAVID SALKIN, M.D., Altadena

The proved and amazing results of long-term spe-
cific chemotherapy have relegated all other methods
of treatment of tuberculosis to a secondary, adjunc-
tive position. Every other type of treatment, includ-
ing rest, exercise, pneumotherapy, surgical collapse,
excision, sanatorium care, home care, isolation
methods and rehabilitation has been modified or
minimized in one or more ways by use of specific
drugs.

There are still unsettled problems in the use of
rest, surgical treatment and chemotherapy, but this
report will briefly discuss only the currently ac-
cepted opinions.

The major requirement for optimal therapy is a
physician who has ultra-modern knowledge of diag-
nosis and treatment of tuberculosis, since the best
chance for control of the disease and education of
the patient is at the very start. Bacterial conversion,
anatomic healing, elimination of symptoms, rehabili-
tation, economic protection, and happiness may
depend on the program of therapy and the plan that
is made for the future.

Other prime principles of treatment are to find
the cases of tuberculosis, to place the patients where
optimal care is available, and to arrange the whole
program in a way which satisfies the patient, his
associates, his pecuniary resources and the public
health rules.

SPECIFIC CHEMOTHERAPY

The major methods of treatment are as follows:
“Chemotherapy” is the term used for treatment with
chemicals, or antibiotics. It can also be called “anti-
microbial” or “antibacterial” therapy. There are a
number of such drugs which have a specific effect
on the tubercle bacillus. The ones used most com-
monly are isoniazid, the streptomycins, and amino-
salicylic acid (para-amonisalicylates) . Other drugs
which either have less effect or more serious toxicity
include pyrazinamide, cycloserine, viomycin, kana-
mycin, thioamide, and tetracycline. (Streptovaricin
and thiocarbanidin are no longer in use.)

Streptomycin (sm) became commercially avail-
able in 1946, the para-aminosalicylates (pas) in
1949, and isoniazid (inh) in 1952. All the infor-

From the La Vina Sanatorium and Hospital, Altadena (Oatway),
and Veterans Administration Hospital, San Fernando (Salkin).

Submitted March 16, 1962.

• The progress and changes in management of
tuberculosis are extensive and dramatic. Chemo-
therapy now leads the list of methods, and com-
binations of drugs containing isoniazid are the
most effective. The use of such drugs in chemo-
prophylaxis has a new and expanding basis of
value.

The other methods of therapy are considered
to be adjunctive. Among them, pulmonary resec-
tion is of greatest value, although needed less
often. Rest may be less complete than once was
prescribed, and of shorter duration ; exercise
may be prescribed sooner and be more vigorous.

Rehabilitation is a part of treatment. It may
be physical, mental, and social restoration or
training. It may often be initiated in the early
phases of treatment. The methods depend on the
individual, the objective, and the pulmonary
disease.

mation on their usage in a chronic disease has been
observed, analyzed and reported in the few years
since then. Our knowledge of drug dosage, toxicity
and clinical effectiveness has been hastened by the
cooperative studies of the Veterans Administration-
Armed Forces group, the U. S. Public Health
Service, the British Medical Research Council, sev-
eral pharmaceutical houses and many physicians
associated with hospitals or private medical groups.

The mode of action of the drugs varies, but all
are chiefly considered to be bacterial suppressants,
and perhaps partly bactericidal. They are delivered
to the lesions by the circulating blood and are
present in the “tissue juices,” but isoniazid is the
one that goes most freely into the cells and spinal
fluid.

The various drugs have been prescribed in many
different ways. Current practice includes the follow-
ing methods :

1. A combination of two drugs for lesions which
are active but do not constitute an emergency. This
regimen and class includes most cases of pulmonary
tuberculosis. The best combinations are INH and
pas, or inh and SM. Two drugs are also used when
there is allergic sensitivity or intolerance to a single
drug (often pas) .

2. A combination of three drugs (inh, pas and
sm) for selected cases of acute massive pulmonary
disease, or acute hematogenous disease. (Some clini-
cians prefer to use three drugs for all cases, but

142

CALIFORNIA MEDICINE

for varying periods of time; others feel that there
is no advantage of three drugs over two. It is diffi-
cult to prove such an advantage, and data compiled
by the Veterans Administration indicate that the
results of inh plus pas are as good as those obtained
with a triple drug regimen.)

3. The use of more than three drugs in cases of
known (or suspected) resistant bacilli.

4. The addition or substitution of secondary
drugs in cases with poor clinical response, even
though the bacilli are susceptible in cultures.

Only a brief summary of data on each drug will
be given here.

Isoniazid is given in tablet form, three times a
day, usually in doses of 300 mg. per day for adults.
A Veterans Administration research protocol is
now testing the toxicity and value of 300 mg. once
a day. The use of higher doses of INH has been
recommended, especially for so-called “rapid inac-
tivators,” but its therapeutic superiority is contro-
versial. Inh is well tolerated, very rarely produces
an allergic reaction, and is rarely toxic in ordinary
doses. Large doses may cause neuritis from vitamin
B6 deficiency, but this condition may be prevented
by daily use of B6 (pyridoxine) . Inh has become
known as the most potent and indispensable factor
in any combination of drugs.

Streptomycin is an antibiotic which is given intra-
muscularly, two or three times a week (or daily) in
doses of 0.5 to 1.0 gm. It can be given as streptomy-
cin sulfate (which may be toxic for the vestibular
portion of the eighth nerve) or as dihydrostrepto-
mycin sulfate (which may affect the auditory por-
tion). These serious toxic effects are not frequent
with two or three doses a week, but both compounds
produce a transient mild irritation of the peripheral
nerves or central nervous system in about a third
of the patients (paresthesias of the face, headache,
somnolence, etc.). Allergic reactions occur in a
small fraction of 1 per cent. There is a current shift
away from dihydrostreptomycin because of reports
of occasional and often subclinical hearing loss
from even a few doses, and production of the drug
is now limited. Some physicians feel that the vertigo
and loss of balance from use of SM is equally com-
mon and serious. It is difficult to choose between
vestibular and auditory hazards, but the present
opinion and restrictions almost eliminate the use
of dihydrostreptomycin.

Para-aminosalicylate (pas) is given as sodium,
calcium and potassium salts, and as a resin. There
is a choice of powder, tablets, enteric coated tablets,
granules and intravenous forms. It produces some
gastrointestinal or general toxicity in at least 25
per cent of patients; is the poorest tolerated of the
major drugs; but, with planning and perseverance,

all but about 5 per cent of patients can take it. It is
given in daily doses of 12 gm., in three divided
doses, with meals. A daily total of less than 8 or 9
gm. is probably not effective, although a single dose
of 6 gm. once a day is being tried. Allergic reaction
occurs in 2.5 per cent of the patients, but desensi-
tization is possible in more than two-thirds of them.

The chief limiting factor in use of the drugs is
not toxicity but loss of bacterial susceptibility (sen-
sitivity) to one or more drugs. The resistance may
occur in a few weeks or months if a drug is given
alone, or if drugs are given irregularly. It tends to
be permanent, and reduces or ends the anti-
microbial effect of the drug. Therefore, no fewer
than two drugs should be given for primary treat-
ment and until it is certain that the sputum is nega-
tive for tubercle bacilli. Pas alone is not a powerful
antibacterial drug but, when given in combination,
it delays the emergence of resistance to SM and inh
for many months; streptomycin and INH also have a
mutually protective effect. The total toxic effect of a
regimen depends on the drugs it contains; any
combination with PAS is less well tolerated. The
best clinical effect is obtained by combinations that
include INH.

The secondary drugs are of special value in situa-
tions where susceptibility has been lost to one or
more of the primary drugs, where primary drugs
cannot be tolerated or where extra effect is needed
for medical or surgical reasons. They include the
following:

Pyrazinamide is clinically effective with inh. It
is given in tablet form, 0.5 to 1.0 gm. two or
three times a day, and is tolerated well except for
occasional nausea, anorexia, etc. It may cause liver
damage, usually reversible although occasionally
serious or fatal, and should be used with great cau-
tion for any period over four months if there is a
history of liver damage or alcoholism. Serial liver
function tests should be obtained.

Viomycin is an effective antibiotic which is given
intramuscularly, may be used as a substitute for
streptomycin, may result in resistance and is a renal
irritant and quite toxic for the auditory nerve when
given daily. A less effective but safer dose is 1 to 2
gm. twice a week.

Cycloserine is an oral antibiotic with a moderate
anti-tuberculous effect. It is given as a powder, in
capsules, 250 mg. two or three times a day. It is
quite often toxic in larger doses, producing irrita-
tion of the central nervous system, convulsions in
5 to 10 per cent of patients, and occasionally psy-
chosis.

Kanamycin is an antibiotic, given orally or hypo-
dermically, in a dose not to exceed 0.5 gm. twice a

VOL. 97, NO. 3

SEPTEMBER 1962

143

day. It is mildly effective, but can be very toxic,
frequently causing progressive deafness.

Neomycin is a powerful antibiotic but its paren-
teral use is contraindicated because of the frequent
occurrence of deafness.

Oxytetracycline is a broad-spectrum antibiotic
with only a slight effect against the tubercle bacillus
even in large doses (3 to 6 gm. daily). It is useful
only as an adjunctive drug.

Thioamide drugs are currently being investigated.

The clinical effectiveness of the drugs used in tu-
berculosis depends on early administration, use of
the best combination given constantly without inter-
ruption, a prolonged period of administration, sub-
stitution or addition of other drugs in case of need,
removal or collapse of lesions when such help is
required, and frequent reevaluation by x-ray and
bacterial tests to show the progress of therapy.

Effects of Chemotherapy on Pathology

Most of the specific drugs are effective only
against tubercle bacillus and have only an indirect
effect upon the tissues and immune processes. The
pathologic changes resulting from successful chemo-
therapy are best studied by serial x-ray observations,
by examination of anatomical specimens and by
animal experiment.

The drugs have a notable effect on the exudative
and productive lesions, resolving them in a rela-
tively short time. They indirectly prevent the further
development of caseation necrosis and decrease the
ultimate extent of fibrosis and emphysema. There
is no evidence that the drugs have a significant
direct effect on already formed necrotic areas except
on ulcerated surfaces where a clearing occurs which
the British call “caseolysis.” All healing processes
occur more quickly with chemotherapy, often in
weeks or months.

The effect of chemotherapy on cavities is also
notable. There may be a pronounced decrease of
peri-cavitary reaction with a thinning of the cavity
wall. The cavity may become smaller. “Blocking”
of cavities and inspissation of their contents occur
more often and rapidly, and fibrosis, hyalinization
and calcium deposition may follow. The mural ul-
ceration and granulation of the draining bronchi
rapidly heal, and a re-epithelialization of the bron-
chocavitary junction occurs which sometimes ex-
tends into the cavity. Use of “the drugs” has
resulted in an “open healing” of cavities, a condition
which formerly was very rare.

The indications for chemotherapy with two or
more drugs are as follows:

• All active tuberculous disease, both pulmonary
and extrapulmonary.

• Disease presumed to be tuberculous but with-

out bacterial evidence. A therapeutic trial should be
used if other likely causes have been excluded, and
especially if the tuberculin test is strongly positive.

There are several logical indications for INH
alone:

• Continuation of treatment after tuberculosis
has officially become “inactive” following use of
multiple drugs. The duration should be a minimum
of 12 months, and it may extend indefinitely.

• Late treatment of “quiescent” lesions after two
or three years of a multiple-drug regimen.

® Primary treatment of minimal and moderately
advanced non-cavernous lesions in which sm and
pas cannot be tolerated.

• Primary tuberculosis without a lesion evident
by x-ray. This is “secondary chemoprophylaxis” for
persons no longer positive to tuberculin tests. Ther-
apy should be started as quickly as possible after
diagnosis, and it has been known to largely prevent
the lesions of hematogenous dissemination. This
usage applies to adults as well as children. It also
applies to infants under four years of age who are
found to be reactive to tuberculin, since the dura-
tion of the infection is limited.

® Prevention of possible relapse in patients who
have “inactive” disease but no recent chemotherapy.
The course of treatment should be one to several
years.

° Treatment of patients with a lung lesion which
is presumed to be tuberculous, but with negative
bacterial tests for tuberculosis. A strongly positive
tuberculin test reaction emphasizes this indication.
Improvement of such lesions during chemotherapy
may be of help in differential diagnosis.

• Protection of patients who are receiving pro-
longed cortico-steroid therapy; patients with sili-
cosis and a positive tuberculin test; patients with
unstable diabetes and a positive tuberculin test, and
patients with a gastric resection and tuberculin
reaction.

• Prevention of infection in persons negative to
tuberculin but in potential contact with “open”
cases of tuberculosis (“primary chemoprevention”)
has just been proved effective in humans. The U. S.
Public Health Service has released a preliminary re-
port on the use of isoniazid among persons in
contact with patients with recently diagnosed dis-
ease, inmates of mental hospitals and Alaskan
natives.

Retreatment is a topic of increasing interest. An
increasing number of patients require a second
course of therapy because of incomplete healing,
reactivation, carelessness, premature discontinuance
of drugs or faulty use of the drugs. A fresh ap-
proach should be used, depending on the sensitivity

144

CALIFORNIA MEDICINE

pattern; a regimen of two or more drugs should be
used; drugs of secondary value should be started;
the drugs most effective in vitro should be selected;
and any drug against which there is considerable
resistance should be discontinued (except possibly
inh).

Future prospects in chemotherapy should include
a more extensive use of drugs as a result of better
case-finding; a wider use of drugs owing to more
precise knowledge of the effects; a better education
of those who administer the drugs; improvement
or discovery of new drugs; and a correlation of
drugs with rest, exercise and surgical treatment.

REST AND EXERCISE

Rest has been called the keystone of treatment
since Dettweiler modified the more vigorous meth-
ods of Brehmer and since Trudeau established his
sanatorium in the United States. The original intent
of rest was to “rest the body, to rest the chest, to
rest the lungs, to rest the lesions.” It attempted to
decrease the volume and mobility of the lungs so
that healing could more easily take place. There
was evidence that this was often effective, even when
there were no other methods to help.

Exercise was reduced to a minimum during the
“rest cure” while the disease was active; it was
later prescribed cautiously, like a strong medicine;
and it was always aimed at not disturbing the chest
until the healing was firm and the hazards of
stress and strain were reduced.

Pathologically and bacteriologically the effect of
the rest-exercise regimen was to allow resolution
of the exudative element, scarring of the remainder
and encapsulation of necrotic foci containing the
bacilli. Many patients had complete healing of
lesions; some became “good chronics” with cavita-
tion and positive sputum (“open positive” lesions) ;
some had relapses of the healing; and some died
of progressive disease.

Since the rest cure was once effective by itself
or with the help of collapse therapy, it should follow
that it is still of value in conjunction with chemo-
therapy. It has become essential only for acute,
seriously ill patients and in cases of hemoptysis. It
is an adjunct when the drugs have given enough
protection. Recent evidence suggests that intensive
bed-rest is not needed for mild or moderately active
lesions in patients receiving effective chemotherapy
and with susceptible bacilli.

Strenuous exercise for prolonged periods should
be avoided if healing is insecure and if the residual
lesions are extensive. Certain therapists have been
using exercise in suitable patients to “harden” the
lesions during rehabilitation. This therapy has been
limited to young males who do not have active

disease. Many of those so treated have had lesions
resected. There is no doubt that exercise tolerance
is greater than has been thought, but age-groups
and physical condition currently seen in most hos-
pitals do not provide ideal indications for vigorous
rehabilitation.

THORACIC OPERATIONS

All surgical procedures have had to be reevalu-
ated in the light of chemotherapy. The number of
operations has been reduced, since many are no
longer necessary. The type of operation to be used
depends on the lesion which is residual after ade-
quate chemotherapy :

• Thoracoplasty is only occasionally used as a
primary proedure. Nowadays many patients are
allowed to continue with persistent cavitation that
previously would have been treated by collapse.
The operation is effective in reducing the volume
of destroyed lung, but it still deforms the chest.
A “secondary” thoracoplastic procedure is occa-
sionally required to supplement some other form of
collapse which has been complicated or has not been
effective. Thoracoplasty may be the method of
choice in some cavitary drug-resistant cases.

° Extrapleural plombage has generally been
abandoned, due to complications and the success of
resections. The exception is use of an extrapleural
prosthesis, with placement of wax or lucite spheres
in a “pocket” which is constructed after fairly large
amounts of lung tissue have been resected (for
example, a lobe plus a segment).

® Extra - periosteal ( subcostal ) prosthesis is
sometimes used in place of thoracoplasty. The peri-
osteum is peeled away from the ribs, the ribs being
left in place; then wax, lucite spheres or plastic
sponge is used to fill the space between the ribs
and the collapsed fascial bundles. The operation is
often less shocking than other thoracoplastic pro-
cedure, retains the chest wall support, avoids
deformity and keeps the prosthesis away from tu-
berculous tissue.

• Resection is the surgical method most fre-
quently used. A successful operation results in re-
moval of the major disease process. The use of
effective chemotherapy prevents the complications
of resection of any type, but it also may eliminate
the need for the resection. There is still a contro-
versy as to the indications for resection, but there
are several trends:

a. Resection of small, closed lesions is now rare,
especially if the aggregate size is less than 4 cm.

b. Resection of “open negative” lesions is less
frequent, especially if some other ailment or the
patient’s age contraindicates, or if the lesions are
bilateral.

VOL. 97, NO. 3 • SEPTEMBER 1962

145

c. Resection of residual lesions is indicated when
the bronchial secretions still contain bacilli. This is
especially so if the bacilli are resistant to one or
more drugs. (The complications in these groups are
naturally higher.)

d. The use of segmental or smaller resections is
decreasing, due to complications, in favor of lobec-
tomy.

e. Morbidity and mortality after operation de-
pend on many factors, including type of disease,
extent of the operation, condition of the contra-
lateral lung, condition of the bronchial walls, the
availability of useful drugs, the skill of the surgeon,
the anesthesia and the postoperative care. Indica-
tions for surgical treatment will probably not change
much more until a bactericidal drug is available.

ADJUNCTIVE THERAPY

All other treatment methods are adjunctive to
chemotherapy.

• Diet now means a balanced amount of food
substances, with adequate calories, sufficient pro-
tein and a supplement of vitamins. There is evidence
that vitamins A and C are particularly necessary for
healing. Foods which disturb the intestinal tract
and decrease tolerance to pas should not be eaten.

• Climate is useful only as it affects a comfort-
able existence. It has no demonstrable good or bad
effects on tuberculosis.

• Heliotherapy is not required for healing, and
Vitamin D is available in food. Sun-bathing should
be avoided if it results in sunburn, but reasonable
amounts are safe and legitimate.

• Symptomatic treatment may temporarily be
needed for cough, pain, etc. Most symptoms dis-
appear or considerably decrease with specific drug
therapy.

• Psychotherapy may be required for several
reasons: The patient may need to be convinced that
therapy is necessary; he may require education and
assurance about tuberculosis. The patient may also
have a tension condition which requires sedative or
tranquilizer drugs. Healing and relapses may be
related to the psychic status. The mechanism by
which this occurs is not yet certain, but it may be
mediated by hormones, and the levels of hormones
may be measured.

• Adrenal corticosteroids are hazardous to use
if tuberculosis is present but not recognized, or is
present but not under control by chemotherapy, or
present but with bacilli not susceptible to the drugs.
The modern steroids are now being found helpful
in:

a. Acute forms of tuberculosis (pneumonic, mili-
ary, meningeal, toxic) .

b. Allergy to essential anti-tuberculosis drugs.

c. Tuberculosis associated with adrenal insuf-
ficiency.

d. Tuberculosis of serous membranes (quicker
absorption, less residues).

e. Tuberculosis associated with other conditions
requiring steroid therapy (collagen diseases, sar-
coidosis, and arthritis).

All of these conditions must be under adequate
and effective treatment with specific anti-tuberculosis
drugs during the administration of corticosteroid
drugs.

• Pneumotherapy. Pneumothorax (intrapleural)
and pneumoperitoneum are rarely used since the
advent of chemotherapy. They should not be for-
gotten, however, since an occasional lesion might
benefit from temporary use of them and because
the complications of pneumothorax have been much
reduced by the chemotherapy. They could also be
useful in cases in which chemotherapy fails. Pneu-
moperitoneum is sometimes used after resection to
raise the diaphragm and allow the expanding lung
more readily to fill the pleural space.

REHABILITATION

The final step in treatment of tuberculosis is
largely one of rehabilitation. The process begins
earlier in treatment, however, when rehabilitation
walks side by side with other methods of therapy.

General Principles

Rehabilitation is the restoration of the handi-
capped to the fullest possible degree of physical,
mental, and social usefulness. The term rehabilita-
tion is comprehensively used to include the voca-
tional, economic, educational, spiritual, recreational
and other elements of living. The need for re-
habilitation in tuberculous patients is especially
great because control of the disease often depends
upon the patient’s personality and activities. Full
recovery is greatly influenced by both physical and
psychosocial factors.

A short-term hospital traditionally deals with the
physical aspects of disease, whereas a long-term
hospital is concerned also with the emotional fea-
tures. It becomes essential that every hospital assess
its needs for rehabilitation with the realization that
it is as important to treat the patient as it is to
treat his disease. The same principles apply to
patients being treated at home.

The degree of rehabilitation to be initiated in a
hospital depends upon the needs of the patients,
the attitude of the hospital staff and the facilities
available in the hospital and community. One or
more phases of rehabilitation should be initiated

146

CALIFORNIA MEDICINE

immediately after the physical appraisal of the
patient has been made.

There has been a decided broadening of the scope
of rehabilitation since the advent of chemotherapy,
and more arduous physical activities than were
permitted in former days may now be allowed. In-
deed, younger patients with good therapeutic results
may return to manual labor or to the military
services.

Vocational rehabilitation, or the training of the
handicapped in an occupation suitable to health and
aptitude, is still needed by many patients. The indi-
cations for such rehabilitation may be considered
generally as follows:

Type of disease — extensive residual, the patient
not likely to stand much physical activity; consider-
able loss of lung tissue; complications such as
emphysema, cor pulmonale or disturbing symptoms;
too great a loss of muscle power to maintain pre-
vious employment.

Type of person — motivated patients anxious to
improve on previous status; males over 40 years,
especially if single; no previous job; no special job
skills, personality disorders; associated psychosis;
little or no education; alcoholism, chronic jail resi-
dence; recalcitrancy.

Vocational rehabilitation is not indicated, of
course, if either the recovery is so good that the
patient can return to any type of physical activity
in an old or new job, or has so much disability
from tuberculosis or its complications that gainful
employment cannot reasonably be expected.

The following listing of stages in vocational re-
habilitation is not necessary sequential, since many
of these steps are simultaneous. The program plan-
ning may even start during the active stage of the
disease. There should be frequent conferences of
the rehabilitation team to assure a coordinated and
steady progress.

1. Evaluation of the medical state; character
of the disease, prognosis; expected recovery; the
physical activity eventually permissible; and the
vocational goal and medical limitations.

2. Emotional condition and its relationship to
the vocational goal. Proper motivation of the patient
is a basic requirement.

3. Vocational testing and counseling.

4. Vocational activities — to include graded ac-
tivity, educational courses, vocational exploration
through occupational and manual arts therapies,
and actual trial at work.

5. Training, in the hospital, school and shop.

6. Job placement. The number of hours the
patient may work per day, the rate of increase and
the ultimate work capacity under normal or limited
conditions should be known at the time of discharge.

Maximum Self-sufficiency. There is an ever grow-
ing need for rehabilitation geared to independent
living in both the general and tuberculous popula-
tion. The indications for this type of training may
be present:

• In tuberculous patients who are being treated
in the hospital or at home.

• In chronic “active” tuberculous patients.

° In cases with such disability as to preclude
gainful occupation.

• In patients who need vocational rehabilitation
but who refuse it.

• In patients over 60 years of age, pensioners
and the retired.

All methods described should be used on an indi-
vidual as well as on a group basis, and particular
emphasis should be given to cultural and recrea-
tional activities. Some types of vocational projects,
with or without remuneration, may also be stimu-
lating and morale-building. No program should be
rigid and inflexible. Many patients over 60 years
of age are capable of vocational rehabilitation;
some patients with chronic disease and with sputum
positive for tubercle bacilli may earn a livelihood
at home; and many patients who at first reject
vocational aid may later be motivated sufficiently
to return to social usefulness.

The Professional Services. Rehabilitation involves
the utilization of many skills. The extent of rehabili-
tation to be attempted in a hospital must depend
upon the size of the hospital, the need for such a
program, the hospital budget, and the attitude of
the administration. The program may include the
following specialists: a vocational counselor, a clin-
ical psychologist, a social worker, chaplain, educa-
tor, recreation director, occupational and manual
arts therapist, in addition to the medical and nurs-
ing staffs.

The program can be more complete if there is
a close liaison with interested agencies such as a
state office of vocational rehabilitation, the National
Tuberculosis Association, the Veterans Administra-
tion, welfare agencies, and private industry. Special
hospital industries and sheltered workshops may be
useful in large centers, and for special types of
patients.

La Vina Sanatorium & Hospital, La Vina Station, Altadena
( Oatway ) .

VOL. 97. NO. 3 • SEPTEMBER 1962

147

Congenital Heart Disease

Changing Concepts in the Surgical Treatment

NORMAN E. SHUMWAY, M.D., RICHARD R. LOWER, M.D.,
EDWARD J. HURLEY, M.D., EUGENE DONG, JR., M.D.,
and RAYMOND C. STOFER, Palo Alto

Technical advances in surgical operations on the
heart are developing so rapidly that the list of in-
operable congenital heart diseases is constantly
diminishing. Yet, much work remains to be done
and many areas are essentially unexplored.

The specialty of cardiac surgery was born in 1938
when Gross and Hubbard performed the first suc-
cessful operation for patent ductus arteriosus.2
Amazing strides have come since that eventful occa-
sion and the future holds hope for even greater
ones. Discussion of them can proceed along ana-
tomic lines, touching on juxtacardiac anomalies
first, continuing with valvular and septal defects and
closing with a glimpse into the fascinating world
of experimental cardiac surgery.

Patent Ductus Arteriosus

Perhaps the purest of all surgical procedures is
division of the uncomplicated patent ductus. The
same anatomic defect in the presence of increased
pulmonary vascular resistance and pulmonary hy-
pertension is a different matter entirely. In fact in
some cases of bi-directional shunting operation is
not feasible, and ablation of the ductus is fatal
when the flow is predominantly right-to-left. Lower
extremity cyanosis of course is the cardinal physical
finding of the latter condition. While simple patent
ductus can he severed with little difficulty, extra
measures are worthwhile in cases in which there
are high pulmonary artery pressures. Moderate hy-
pothermia to permit cross-clamping of the aorta
above and below the ductal ostium is useful. If the
pulmonary artery pressure increases during a trial
period of ductal obstruction, the prognosis attending
division of the ductus is ominous. If the pulmonary
artery pressure falls, one may proceed with the
operation confident that the pulmonary arteriolar
resistance is not fixed and that the high pressure

From the Department of Surgery, Stanford University School of
Medicine, Palo Alto.

Supported in part by Research Grant H-4658 of the National
Heart Institute.

Presented as Part of a Panel before a Joint Meeting with the Sec-
tions on Internal Medicine and General Practice and Pediatrics, at
the 91st Annual Session of the California Medical Association, San
Francisco, April 15 to 18, 1962.

• Probably tbe most important continuing ad-
vance in tbe treatment of congenital heart dis-
ease is the ever-diminishing risk of operations
on tbe open heart. The uncomplicated septal
defect or valvular stenosis is now corrected un-
der direct vision with essentially the same risk
as that which attends the routine operation for
patent ductus arteriosus. Perfusion systems, and
corrective heart operations, are now available for
any patient who weighs 10 kilograms or more;
palliative operations are often prescribed for
critically ill patients weighing less than 10 kilo-
grams.

With respect to the future, successful removal
and replantation of the heart in dogs opens the
door for imaginative approaches to many states
now considered inoperable. Still more inspiring
is the realization that cardiac homotransplanta-
tion is surgically feasible and immunologically
possible, if specific transplantation antigens can
he isolated.

resulted primarily from flow rather than from ar-
teriolar occlusions.

Operative disasters are infrequent if the high
pressure ductus is clamped in such a way as to
avoid the thin-walled pulmonary artery. With the
body temperature at 32° C., the aorta is occluded
above and below the ductus, and the ductus is
clamped with a single instrument. The aortic and
ductus suture lines lie at right angles to each other.

We believe that patent ductus always should be
divided rather than ligated. We prefer to do the
operation in the pre-school age group but do not
hesitate to carry it out during infancy if the situa-
tion demands. In infants with life-endangering but
correctable cardiac anomalies, the techniques of
anesthesia may be more important than the surgical
method. There are no acceptable data on mortality
from operations for uncomplicated patent ductus
arteriosus.

Occasionally aortic septal defect may closely mimic
patent ductus. Cineaortography then is very helpful
in the diagnosis. In perhaps 90 per cent of cases,
patent ductus may be diagnosed without special
methods. Catheterization is essential in atypical duc-
tus or if the patient has pulmonary hypertension.

148

CALIFORNIA MEDICINE

Coarctation of the Aorta

Resection of the aorta for coarctation with end-
to-end anastomosis was another early operation for
congenital diseases of the heart and great vessels.
The pathologic physiology is more complicated in
this condition than in patent ductus. Associated con-
genital heart disease is often noted in patients with
coarctation of the aorta. So frequent is this asso-
ciation that we look for another cardiac lesion in
any infant in trouble from aortic coarctation.

In previous years it was customary to defer op-
eration until the patient was between 10 and 20
years of age. This policy is certainly still acceptable,
but earlier intervention is gaining sanction. The fear
that the aorta at the site of anastomosis, if carried
out in infancy, would not grow sufficiently to accom-
modate the patient later is now largely overcome by
experience. The reduction in mortality which can he
achieved by earlier operation is significant. Grafts
should be used only rarely.

The syndrome of abdominal pain after resection
of a coarcted segment of aorta is well documented,
but the cause remains obscure. The drastic change
in circulatory dynamics postoperatively no doubt
accounts for the clinical manifestations.

Vascular Rings

Little has been added lately to the surgical knowl-
edge of vascular ring anomalies. Angiographic
methods help greatly in planning the operative pro-
cedure. Neglected states of esophageal compression,
usually by a ligamentum arteriosum, were recently
identified in a number of adults and treatment was
carried out. After the diagnosis is made, age should
not preclude operative intervention if symptoms are
present.

We treated an infant a year ago who had a patent
ductus and coarctation of the aorta with a right
subclavian artery taking off below the aortic stric-
ture. The pulse at the right wrist, weak before oper-
ation, became easily palpable after division of the
anomalous subclavian artery. Apparently the flow of
blood preoperatively was from the right arm into
the descending thoracic aorta.

Palliative Operations

Many of the available palliative procedures (as
distinguished from surgical treatment of the open
heart) are used in infants too small for corrective
operations.

Transposition of the great vessels. While the
Baffes modification of Varco’s original operation
still is used in some quarters,1 for infants with trans-
position of the great vessels, we have more confi-
dence in the creation of an atrial septal defect. Any
procedure that promotes greater mixing between the
two circulatory streams should have merit. We know

VOL. 97, NO. 3 • SEPTEMBER 1962

of one patient 18 years old who had Blalock’s anas-
tomosis at age 4 and is alive and reasonably well
with transposition of the great vessels. She also has
pulmonic stenosis.

Tetralogy of Fallot and pulmonic atresia. A Bla-
lock or Potts anastomosis may be useful in an infant
weighing less than 10 kilograms, who has critically
deficient pulmonary blood flow. While smaller oxy-
genators are under development to permit perfusion
of tiny infants, we have successfully perfused and
treated several 10-kilogram patients with a variety
of lesions. It seems clear that the use of hypothermia
alone for pulmonic stenosis is outmoded in view of
improvements in techniques for extracorporeal cir-
culation in infants.

Ventricular septal defects in infants. The predic-
tably high mortality in infants less than one year old
submitted to open-heart operations for ventricular
septal defects led us to join other proponents of
the Muller-Dammann pulmonary artery banding
procedure. The idea of converting these cases into
cases of acyanotic tetralogy has been substantiated
by clinical trial despite the fact that it was origin-
ally conceived because of slow development of
perfusion systems.

Open-Heart Operations

Probably the most notable advance in the general
area of open-heart surgery is the continuing reduc-
tion in operative mortality and the more aggressive
surgical attitude permitted thereby. Defects in the
cardiac septa are closed routinely without fear of
bleeding and embolism attributable in previous
years to inexperience and untried equipment. The
artificial heart-lung machine now presents no more
additional risk than that associated with the general
anesthetic. Congenital lesions of the valves of the
heart are also being treated with increasing success
and diminishing risk.

Elective cardiac arrest, so essential to operation
for correction of a variety of cardiac anomalies, has
become a relatively innocuous procedure. Appar-
ently, heart muscle is no more susceptible to injury
from oxygen deprivation than any other muscle in
the body; in fact it may be more resistant to anoxic
insult than ordinary skeletal muscle.

Valves

While the first operations for pulmonic valvular
stenosis were done blindly, direct vision methods per-
mitted by general hypothermia soon were adopted.0
At present open operations on the pulmonic valve
should probably be carried out with the aid of
extracorporeal circulation because of the incidence
of masked ventricular septal defects. The pulmonic
valve is exposed by a supravalvular incision in the
pulmonary artery, and elective cardiac arrest is not

149

used. No incision is made into the thick right ven-
tricle unless a ventricular septal defect is discovered
by the appearance of bright red blood in the pul-
monary arteriotomy.

The history of operative approaches to the aortic
valve closely parallels that previously stated for the
pulmonic valve. Blind operations which were suc-
cessful, however, for the pulmonic valve proved to
be not only unsuccessful but also often fatal when
used on the aortic valve. The reason of course is that
aortic insufficiency was brought about by the efforts
to open the aortic valvular stenosis without seeing
the field. Hypothermia permitted some successful
operations on congenital aortic valvular stenosis, but
the advent of safe extracorporeal circulation has
paved the way for the current choice of operative
methods. Elective cardiac arrest is utilized along
with a supravalvular aortic incision. The consecutive
experience in aortic valve lesions of the congenital
variety at the Palo Alto-Stanford Hospital is shown
in Table 1. With respect to congenital aortic valvu-
lar stenosis, it must be emphasized that great care
should be taken not to make the valve insufficient.
Very frequently these are bicuspid valves with only
a remnant of a third commissure. Under these con-
ditions it is clearly important not to attempt devel-
oping a commissure which may be only a raphe.

We recently operated upon a 10-year-old boy with
familial subvalvular hypertrophic obstruction of the
left ventricular outlet. The aortic valve had been
pinched out of the heart by the hypertrophic left
ventricle, and excellent exposure of the entire ven-
tricular septum could be obtained through an
aortotomy. With sharp dissection a valley was de-
veloped anteriorly, extending from immediately be-
low the normal valve to the left ventricular apex.
The immediate operative result was gratifying. We
have dealt with only one case of supravalvular aortic
stenosis, and this was relieved by cutting through
the tight band into the noncoronary bearing sinus.
A diamond-shaped patch of Teflon was sutured in
such a way as to increase the diameter of the aorta.
The kind of elective cardiac arrest that we favor is
that provided by anoxia and local hypothermia.8
Coronary perfusion is not utilized in most cases of
congenital aortic stenosis.

Congenital disease of the mitral valve is often
associated with other defects such as coarctation of
the aorta and patent ductus. Stenosis may be the
result of severe valvular derangement, and even
direct vision procedures may be unrewarding. For
the patient with valvular insufficiency, annuloplasty
is helpful. We utilize peripheral venous cannulation
for blood return to the oxygenator and left thor-
acotomy. The heart is not arrested. Sutures must
be placed in the annulus in such a way as to rotate

TABLE 1. — Data on Correction of Congenital Aortic Stenosis
During Cardiopulmonary Bypass*

Number
of Cases

Subvalvulart

Valvular

Supravalvular

* There were no deaths.

t Includes one patient with

familial hypertrophy of the left ven-

tricular outlet.

the available valve tissue into the mitral orifice.
With the left side up, air embolism is avoided and
exposure of the valve is excellent.3

Septa

Hypothermia provided a method for the first suc-
cessful open-heart operation, which was closure of
an atrial septal defect,5 but extracorporeal circula-
tion now is generally favored for any approach to
the cardiac septa. At the Palo Alto-Stanford Hospital
there has been only one death in 75 operations for
defects of the atrial or ventricular septum. One
word of caution in the surgical treatment of atrial
septal defects would apply to the prevention of air
embolism. All air must be removed from the left
side of the heart before terminating the extracor-
poreal source of circulation. Filling the left atrium
with saline solution immediately before placing the
last suture in the atrial septal defect and simple
aspiration of the left ventricle before closing the
right atriotomy, minimize the chance for air em-
bolism. In older patients with large atrial septal
defects use of a patch of synthetic plastic material
may be necessary to close the defect without tension.

Elective cardiac arrest is used in most cases of
ventricular septal defect. However, in patients with
very small shunts elective cardiac arrest is not always
necessary. Even when the aorta is not clamped a left
atrial catheter is used to keep the left side of the
heart free of blood that drains from the bronchial
vessels. All edges of the defect are more readily
visualized if the field is dry. Primary suture of the
defect and reinforcement with the plastic prosthesis
is the usual method of closure. There has been no
case of sustained complete heart block in a patient
with a ventricular septal defect.

Endocardial Cushion Anomalies

Most defects in this category entail multiple in-
volvement of septa and valves. Atrial septal defects
of the ostium primum type may occur without
deformity of the mitral valve, but this is rare. More
frequently the anomaly comprises a low atrial septal
defect, a cleft in the aortic leaflet of the mitral valve
and a small depression in the ventricular septal ridge
with a cleft tricuspid valve.

150

CALIFORNIA MEDICINE

The anatomic problem may be so severe that
surgical correction is a great challenge, or the task
may be exceedingly easy. As with operations for
correction of ventricular septal defects, the prog-
nosis may well depend on the state of the pulmonary
vascular bed. Heart block is largely prevented by
placing sutures in the ventricular septal ridge with
the heart beating. Any interruption of conduction
is immediately identified. We almost always use
prosthetic material for closure of the defect.

Two points in diagnosis are worth emphasizing:
(1) Any infant or child in trouble on the basis of
what appears to be an atrial septal defect probably
has the endocardial cushion anomaly; (2) the pres-
ence of left axis deviation on the electrocardiogram
should arouse suspicion of this cardiac lesion.

Tetralogy of Fallot

Perhaps the most interesting of all congenital
heart diseases is Fallot’s tetralogy or pentalogy.
Lillehei showed that this anatomic complex w7as
totally correctable if not curable.6 We use anoxic
cardiac arrest with local hypothermia and almost
uniformly enlarge the right ventricular outflow tract
w ith a Teflon gusset. Primary suture of the defect is
reenforced w ith a plastic patch sutured circumferen-
tially to the right ventricular endocardium. Anomal-
ous muscle bundles which tend to separate the
infundibular chamber from the right atrium must
be recognized and excised. The experience with such
cases at the Palo Alto-Stanford Hospital is shown
in Table 2.

Experimental Operations on the Heart

In the treatment of congenital heart disease the
use of functioning prosthetic devices may have little
ultimate application. In light of the continuing mor-
tality associated with implanting prosthetic aortic
and mitral valves in patients wdth acquired disease,
it seems unlikely that such devices will be widely
used in young persons. It is a surgical defeat cer-
tainly when existing tissue cannot be arranged in a
more satisfactory functional state than that which is
provided by any prosthetic device. The natural
events of wound-healing are almost as unfriendly
to prosthesis as the immunologic reaction is to
homografts.

After some success with the study of whole heart
homotransplants, we turned to the interesting prob-
lem of excision and isotopic replacement of the
cardiac autograft. Improvements in apparatus for
extracorporeal circulation and elucidation of the fact

TABLE 2. — Total Correction o f Tetralogy of Fallot (Consecutive
Procedures I

Number of cases 16

Age range 19 months to 44 years

Right ventricle outflow gusset.. 14
Previous shunt 3*

Complications 1 heart block (asymptomatic)

Deaths None

‘Two patients with end-to-end Blalock anastomosis.

that the heart can recover after long periods of
oxygen lack permit a glimpse into the future when
a heart may actually be removed from the body,
surgically corrected, and then replaced. Experiments
have been completed which suggest that no untoward
effects result from total separation of the heart from
its nerve supply.4 Obviously, many of the complex
congenital cardiac diseases now inoperable could
become correctable through new, imaginative ap-
proaches.

Finally, the elusive goal of cardiac homotrans-
plantation has been achieved in experimental
animals with survival as long as three weeks.' Ho-
mograft rejection, the bete noir of long-term homo-
transplantation, is under study in these animal
preparations.

Department of Surgery, Stanford University School of Medicine,
Palo Alto (Shumway).

REFERENCES

1. Baffes, T. G., Lev, M., Paul, M. H„ Miller. R. A.,
Riker, W. L., DeBoer, A., and Potts, W. J.: Surgical correc-
tion of transposition of the great vessels: A five-year survey,
J. Thor. & Cardiovasc. Surg., 40:298, 1960.

2. Gross, R. E., and Hubbard, J. P.: Surgical ligation of
the patent ductus arteriosus, J.A.M.A., 112:729, 1939.

3. Hurley, E. J., Dong. E., Jr., Stofer, R. C., and Shum-
way, N. E.: Peripheral venous cannulation in total cardio-
pulmonary bypass, Surg., Gynec. & Obst., in press.

4. Hurley, E. J., Dong, E., Jr, Stofer, R. C., and Shum-
way, N. E.: Isotopic replacement of the totally excised
canine heart, J. Surg. Research, 2:90, 1962.

5. Lewis, F. J., and Taufic, M.: Closure of atrial septal
defects with the aid of hypothermia; experimental accom-
plishments and report of a successful case. Surgery, 33:52,
1953.

6. Lillehei, C. W., Cohn, M., Warden, H. E., Read, R. C.,
Aust, J. B., DeWall, R. A., and Varco, R. L. : Direct vision
intracardiac surgical correction of the tetralogy of Fallot,
pentalogy of Fallot, and pulmonary atresia defects, Ann.
Surg, 142 :418, 1955.

7. Lower, R. R, and Shumway, N. E.: Studies on ortho-
topic homotransplantation of the canine heart, Surg. Forum,
11:18, 1960.

8. Shumway, N. E, Lower, R. R, and Stofer, R. C.: Se-
lective hypothermia of the heart in anoxic cardiac arrest,
Surg, Gynec. & Obst, 109:750, 1959.

9. Swan, H, Cleveland, H. C, Mueller, H, and Blount,
S. G, Jr.: Pulmonic valvular stenosis; results and tech-
nique of open valvuloplasty, J. Thor. Surg, 28:504, 1954.

VOL. 97, NO. 3 • SEPTEMBER 1962

151

Management of Peripheral Arterial
Occlusive Disease

TRAVIS WINSOR. M.D., Los Angeles

Certain pathologic conditions of the blood ves-
sels in aged persons were described as early as 1513
by Leonardo da Vinci. Following this, physiologic
studies prompted by the work of William Harvey
in 1688 have expanded our knowledge of the normal
circulation. In recent years numerous organic and
functional peripheral arterial occlusive diseases
have been studied and the studies have served as a
basis for modern therapy. It is the purpose of this
paper to discuss the medical therapy of the oblitera-
tive arterial diseases, placing special emphasis on
arteriosclerosis obliterans because of the high inci-
dence of this disease.

PERIPHERAL BLOOD VESSELS IN HEALTH AND DISEASE

Vasomotor tone and vasospasm. The peripheral
blood vessels normally are in a state of partial vaso-
constriction which is called vasomotor tone. This, at
any moment, is the net result of numerous vaso-
dilating and vasoconstricting forces which are of
nervous, hormonal, chemical, metabolic, physical
and environmental origin. The tone may be modi-
fied by anxiety, sympathomimetic or sympatholytic
drugs such as amphetamine or mecamylamine; by
the products of ischemia of muscle (dilators) or
kidney (constrictors), by exercise, by pituitrin, thy-
roid, epinephrine or nor-epinephrine, by heat and
cold and by disease. Vasomotor tone should be
differentiated from vasospasm which is a pathologic
condition characterized by episodic constriction of
vessels resulting in ischemia as seen typically with
Raynaud’s disease.

V asomotion in muscle and skin. Anatomic differ-
ences between muscle and skin vessels may account
for differences in their behavior. Skeletal calf muscle
contains about ten times more capillaries and fewer
sympathetic nerve fibers than the skin of the toes,
and the latter has a relative abundance of arterio-
venous shunts. The muscle vessels dilate readily
from metabolites from exercise, local heat, ischemia,
circulating epinephrine and epinephrine-like drugs
such as nylidrin (Arlidin®) ; while skin vessels are

Presented as part of a Panel on the Management of Occlusive Arte-
rial Disease at the First General Meeting at the 91st Annual Session
of the California Medical Association, San Francisco, April 15 to 18,
1962.

From the University of Southern California School of Medicine and
the Wiley Winsor Memorial Heart Research Foundation, Inc.

• The proper use of medical therapeutic agents
in the management of peripheral arterial occlu-
sive disease must be based upon a thorough
understanding of the factors controlling vasomo-
tor tone and vasospasm, mechanisms regulating
blood flow in skin and muscle, factors favoring
nutritional and shunt flow, effects of the diver-
sion of blood from one vascular bed to another,
muscle contraction as a factor which may limit
the blood flow to a part, epinephrine sensitivity
after sympathectomy, and the effects of vaso-
dilator drugs on the local and total circulations.

There are six major classes of therapy for
peripheral arteriosclerosis: General medical care,
administration of vasodilator drugs and admin-
istration of anticoagulants, sympathectomy, di-
rect vascular operation and amputation. In many
cases the most successful treatment is a combi-
nation of medical and surgical therapy.

influenced by sympathectomy and sympathetic block-
ing agents and certain drugs such as tolazoline
(Priscoline®) .

Nutritional and shunt flow. The interchange of
nutrients between capillary and tissues is a most
important function of the circulatory system. The
skin of the acral portions of the body is richly sup-
plied with arteriovenous shunts which, when closed
completely, direct the blood through the nutritional
vessels. When the shunts are wide open, they may
detour the major portion of the blood through the
shunts, thereby inhibiting the nutritional circulation.

Diversion phenomenona. Normally, at rest, all the
circulating blood (about 5 liters per minute) passes
through the right ventricle, lungs, left ventricle and
aorta. Only a portion, however, flows through other
vascular beds such as the splanchnic, renal, volun-
tary muscular, cerebral, skin and coronary circu-
lations. Only 16 per cent flows through resting
voluntary muscle and 5 per cent flows through the
skin. With arterial disease, distribution of blood
flow is altered and blood is often diverted away from
the diseased areas to healthier vascular beds. The
diversion theory postulates that distal to an obstruc-
tion which limits the inflow of blood to a part, an
increase in circulation ( local decrease in peripheral
resistance ) in one vascular bed will be associated
with a decrease in circulation in another vascular

152

CALIFORNIA MEDICINE

bed1 (Figure 1). For example, in the presence of a
popliteal artery obstruction which limits the amount
of blood available to the calf and foot, there may
be enough blood to supply the skin and the muscle
at rest, hut with exercise vasodilatation occurs in
calf muscle which lowers the vascular resistance in
this area. Consequently blood is diverted away from
the skin of the foot to supply the exercising calf
muscle. Clinically this is observed as blanching of
the skin after exercise in patients with obstructive
arterial disease.

Muscle contraction and blood flow. Blood flow
often is dependent upon the relationship between
intra and extravascular (muscle) pressures. In the
presence of disease such as Buerger’s disease which
lowers the intra-arterial pressure, contraction of
the muscles around an artery or other vessel often
is sufficient to interfere with flow. This may occur
in such occupations as truck driving, in which a
steering wheel is held firmly in the hands. Here, the
forearm muscles contract and produce ischemia of
the hands or digits.

Epinephrine sensitivity. This develops about a
month after sympathectomy, especially if the opera-
tion was postganglionic and in the upper extremity.
It is for this reason that adrenergic blocking agents
such as azapetine I Ilidar®) are useful after op-
eration.

Vasodilators and the total circulation. Local vaso-
dilators often increase the circulation through
dilated vessels while decreasing the circulation else-
where. Where this occurs locally, the cardiac output
and blood pressure remain constant (Figure 2).
Generalized vasodilatation, in the sense that there
are more dilated vessels than constricted vessels in
the body, requires an increased cardiac output to
maintain adequate circulation in all areas and a
constant blood pressure (Figure 3). Tachycardia is
seen commonly when ganglionic blocking agents are
administered.

THERAPY OF PERIPHERAL ARTERIOSCLEROSIS OBLITERANS

There are five major classes of therapy for periph-
eral arteriosclerosis obliterans. These are general
medical care and administration of vasodilators, use
of anticoagulants, sympathectomy, direct vascular
operation and amputation.

General Medical Care

General instructions. Walking or exercising to the
point of pain is permissible. The stride should be
shortened by 25 per cent to slow the walking rate
and to extend the walking distance. This is advised
on the basis of experiments which show that exer-
cise of the calf muscle in patients with arterial
disease results in a diversion of blood away from

FAUCET

SHOWER

MAIN

PIPE

LINE

Figure 1. — The diversion phenomenon can be demon-
strated by comparing blood flow in a vessel to the flow
of water in a pipe line supplying a shower and a faucet.
When the main pipe line is open, there is sufficient water
for the shower and the faucet, but with a partial obstruc-
tion to the main pipe line the head of pressure is only
sufficient to supply the faucet.

2 0 0 0

40 0 0

2 0 0 0

Tool

4 0 0 0

3 0 0 0

-n

Figure 2. — Local vasodilatation (cardiac output and
blood pressure constant). (A) Before vasodilatation the
cardiac output is 4,000 cc. per minute and the blood flow
in each of the two vascular beds is 2,000 cc. (B) Alter
local vasodilatation in one vascular bed the flow increases
in one area at the expense of another hut the cardiac
output remains constant.

the foot to the exercising muscle. Thus, to continue
walking during pain may produce damage to the
skin of the foot and toes. It has been suggested that
walking, even in the presence of pain, promotes the
development of collateral circulation, hut the evi-
dence for this proposition is meager.

Phe head of the bed may he elevated four inches,
and the patient should he warned against the foot-up
position. It should be stressed that the feet should
he below heart level for arterial disease and above
heart level for venous disease. The foot-down posi-
tion allows gravitational forces to favor blood flow

VOL. 97, NO. 3 • SEPTEMBER 1962

153

Figure 3. — Generalized vasodilatation; an increase in
cardiac output is necessary to maintain Mood pressure.
(A) Before vasodilatation the cardiac output is 4,000 cc.
per minute and the blood How in each of two vascular
beds is 2,000 cc. (B) Generalized vasodilatation results
in an increased cardiac output in order to maintain the
level of the blood pressure.

into the foot through the arterial channels. Blood is
returned from the dependent limb to the heart
through the venous channels against gravity with
the aid of venous valves, muscle movement and
respiration. Buerger’s exercises are prescribed when
severe ischemia is present. They have been modified
as follows: The patient sits for 15 minutes on the
side of the bed, wearing warm stockings and pa-
jamas to prevent cooling, his feet supported by a
pillow on the floor. The pillow should be high
enough so that the bed does not compress the vessels
at the back of the knees. After about 15 minutes, or
if swelling develops, the patient assumes the hori-
zontal position to favor venous dumping. After 15
minutes the procedure is repeated. The foot-up posi-
tion originally described by Buerger is eliminated
because it produces ischemia of the tissues. Mod-
erate indirect body heating in the form of warm
clothing is beneficial while excessive body heating
is avoided as it may produce a diversion of blood
away from the rigid, diseased vessels to the more
elastic vessels which are capable of dilating. Nico-
tine should be stopped or reduced in most cases,
particularly in patients with Buerger’s disease and
in those with atrophy or ulceration of the skin.
Nicotine unquestionably limits the blood flowthrough
the skin of the limbs in many normal persons as
well as in those with peripheral arterial disease.
It is of interest to note that the flow in a limb
following sympathectomy does not decrease after
smoking, as one site of nicotine action is the sym-
pathetic ganglion. Direct heat and prolonged soaks
generally are inadvisable. However, short soaks may
be necessary to remove debris and crusts and to
promote drainage. Appropriate diets should be given
if the blood cholesterol or triglycerides are high or
if diabetes is present.

TABLE 1. — Sites of Action of Various Vasodilating Drugs

Site

Agent

Cortex

..Barbiturates

Hypothalamus

-Dihydro ergot alkaloids
(Hydergine®)

Sympathetic ganglia

..Ganglionic blocking agents:
Tetraethylammonium chloride
(Etamon®)

Camphorsulfonate (Arfonad®)
Mecamylamine ( Inversine®)
Trimethidinium
Pentolinium (Ansolysen®)
Hexamethonium
Chlorisondamine (Ecolid®)

Myoneural junction

..Adrenergic blocking agents:
Azapetine (Ilidar®)
Phenoxybenzamine
(Dibenzyline®)

Dihydro ergot alkaloids
(Hydergine®)

Tolazoline (Priscoline®)
Phentolamine (Regitine®)

Smooth muscle of vessels..

. Direct acting drugs:

B-pyridylcarbinol (Roniacol®)
Nicotinic acid

Cyclandelate (Cyclospasmol®)
Nylidrin (Arlidin®)
Isoxsuprine (Vasodilan®)

Vasodilators for ischemia of the skin. Skin dilators
such as azapetine (Ilidar®) and tolazoline (Prisco-
line®) alone or in combination are advisable. The
average starting dose of Ilidar® is 25 mg. four times
a day. Priscoline® in the 80 mg. long-acting form
may be administered every 12 hours. Alcohol in
the form of whiskey, 45 cc. orally 2 or 3 times a
day, is of value if there are no contraindications
such as cirrhosis of the liver, gastritis, peptic ulcer,
alcoholism or individual idiosyncrasy. Alcohol is an
effective skin dilator with a direct action on the
blood vessel walls. It also has a central site of action,
which favors vasodilatation.

The available vasodilating agents have sites of
action which are shown in Table 1. When vaso-
dilating therapy is employed, it is well to use agents
in combination, for no one drug is sufficiently effec-
tive alone. Often muscle ischemia ( intermittent
claudication) and atrophy or ulceration of the skin
occur simultaneously. Here, the skin dilators and
muscle dilators should be used in combination. For
example, alcohol, Ilidar® and Priscoline® may be
used together to dilate the vessels of the skin, and
Arlidin® may be given to dilate muscle vessels and
increase cardiac output. The more useful vasodi-
lating agents often are those which have adrenergic
blocking properties, for example Ilidar®, Dibena-
mine® and Priscoline®, as they block some but not
all of the physiologic effects of circulating epi-
nephrine.

Intra-arterial therapy may be employed in patients
with an acute embolus or thrombosis. The agents

154

CALIFORNIA MEDICINE

are injected directly into an appropriate vessel, such
as the femoral artery. In the presence of poor cir-
culation the drug is diffused slowly into the tissues.
Priscoline®, Hydergine®, Arlidin® and Vasodilan®
have been used in this way. Priscoline® and Hyder-
gine® have their greatest effect on increasing the
skin circulation while Arlidin® and Vasodilan® in-
crease muscle circulation primarily. In some cases
a diversion of blood is manifest by a significant
increase in muscle circulation at the expense of
skin circulation and there appears a decrease in tem-
perature and blanching of the skin of the toes for
as long as a half-hour after the intra-arterial in-
jection of a muscle dilating drug.

Physical therapeutic procedures. Use of an oscil-
lating bed along with a vasodilator, such as alcohol,
helps increase skin circulation. The bed should os-
cillate from horizontal to foot-down position, thereby
favoring gravitational inflow through the arteries
during the foot-down position and venous dumping
during the horizontal position. The bed prevents
edema which might occur if the feet remained de-
pendent for long periods. Also, intermittent venous
dumping by periodic compression of the limbs with
the feet in a dependent position may be helpful, and
is a new form of therapy which is theoretically
sound and is being investigated. Diathermy, ultra-
sound and the Pavex boot are not generally helpful.

Anticoagulants

Long term anticoagulant therapy probably is
indicated after surgical operation and in patients
with disease of the small vessels and in those with
advanced, diffuse vascular disease where surgical
treatment is not practical. The value of anticoagu-
lants in peripheral vascular disease has not been
studied as completely as in coronary artery disease,
nor has it been completely evaluated statistically.
However, the layering of clotted blood that is seen
in aneurysms and in thrombosed peripheral vessels
strongly suggests that periodic coagulation of blood
is often a factor in limiting the blood flow to the
periphery. It would seem that anticoagulants should
be used while further investigations are being made.

Sympathectomy

Sympathectomy is indicated early in the course
of certain peripheral arterial diseases if sympathetic
vasoconstrictive tone is high, rather than late in the
course of the disease when organic changes pre-
dominate. Sympathectomy is performed when the
cause of high vasomotor tone is impulses traveling
over the sympathetic nervous system and not when
the cause is constriction due to other causes. The
role of the sympathetic nervous system is assessed
readily in the lower extremities by a posterior tibial
nerve block and in the upper extremities by a

brachial plexus exit block which is performed by
injecting 2 per cent procaine solution near the
origin of the biceps muscle or by a cervical sympa-
thetic block. Generally, sympathectomy for the upper
extremities is relatively unsatisfactory because of
epinephrine sensitivity which develops in a matter
of a few months and because of what appears to be
regrowth of sympathetic nerves after a period of
about two years. Also, often Raynaud’s phenomenon
proves ultimately to be a manifestation of a collagen
disease such as disseminated lupus which in some
cases can be diagnosed only by prolonged study.
In such situations sympathectomy is of only transi-
ent benefit. Sympathectomy of the lower extremities
is of greater value in properly selected cases because
epinephrine sensitivity does not develop as readily.
Sympathectomy is indicated mainly to improve the
circulation of the skin of the lower third of the legs
and of the feet. Sympathectomy does not increase
muscle circulation significantly, nor is it used to
influence intermittent claudication. Ulcers of the
toes, if small, may heal after sympathectomy. This
procedure is of value in patients with Buerger’s
disease involving the lower extremities and is
frequently performed for this condition. It is
employed also for causalgia of the lower and some-
times of the upper extremities. It is seldom per-
formed in patients with diabetes because of the
associated neuropathic condition which often pro-
duces autosympathectomy. Sympathectomy should
not be performed as a last resort or because all
other measures have failed. A positive clinical indi-
cation that sympathectomy may be helpful is the
conversion of a cold, wet, white limb with con-
stricted veins to one that is pink and warm with
dilated veins when a posterior nerve block is
performed.

Direct Arterial Operations

From the internist’s point of view it appears that
thromboendarterectomy for treating arteriosclerosis
obliterans is a satisfactory procedure when employed
proximal to the superficial femoral artery. Replace-
ment or by-pass grafts are usually successful for
treatment of abdominal aneurysms. Generally, iliac
artery replacement or thromboendarterectomy in
these locations is successful, with little tendency
toward recurrence of thrombosis. Unplugging of the
deep femoral artery is a useful procedure which can
restore sufficient blood to the limb, even though a
superficial femoral artery be obstructed, to cause
healing of ischemic ulceration of a foot. Throm-
boendarterectomy of the common femoral artery
may be successful. In the case of thromboendarterec-
tomy or a by-pass graft of the superficial femoral
artery at the adductor canal or at the popliteal artery
and distally, there is a greater tendency toward

VOL. 97, NO. 3 ♦ SEPTEMBER 1962

155

recurrence of thrombosis and there is a reasonable
chance that a year after either a graft or thrombo-
endarterectomy the vessel will not be patent. Homo-
grafts have a tendency to dilate and for this reason
prosthetic devices such as Teflon grafts are em-
ployed. It is probable that anticoagulant therapy
is not necessary after repair of aortic aneurysms or
iliac arteries but it seems indicated in patients who
have had operations on the femoral or smaller
vessels.

Amputation

Amputation should be performed before pain
becomes intolerable and before infection spreads or
toxemia develops. It should be performed through
tissue in which the circulation is good. This can be
judged clinically by vasographic or aortographic
examination or by making incisions through ische-
mic tissue at the time of operation to determine
whether or not bleeding occurs.

Special Problems

Intermittent claudication. The ability to walk is
a good test of the muscle circulation, for exercise
in the presence of ischemia produces pain. Medically
this symptom is treated by shortening the stride,
teaching the patient to walk slowly, avoiding hill
climbing and giving muscle dilator drugs such as
nylidrin (Arlidin®) or isoxsuprine ( Vasodilan®) .
Cyclandelate (Cyclospasmol®) is reported to in-
crease walking ability also. It should be pointed out
that metabolites, direct limb heating, exercise, hy-
poxia and epinephrine all increase muscle circula-
tion. The effect of sympathectomy is irregular and
at best minimal. Surgical operation on the large
vessels often is curative. Usually, intermittent claudi-
cation without atrophy or gangrenous changes does
not require surgical measures. Excessive lowering
of the systemic blood pressures with hypotensive
drugs should be avoided and if blood viscosity is
greater than normal, as in polycythemia vera, it
should be corrected.

Neuropathy. This may be peripheral or radicular,
and may be due to peripheral arteriosclerosis with
ischemia. Diabetes produces neuropathy which is
often bilateral and symmetrical and may precede
typical large vessel arteriosclerosis and ischemic
neuropathy. Ischemia often produces unilateral ab-
normalities. Neuropathy due to these causes must
be differentiated from that due to pernicious anemia,
syphilis, malnutrition, toxic states and nerve com-
pression in and around the spine and lumbar discs.
When due to ischemia, with or without diabetes,
vitamin B12 with B complex (for example, 1 cc. of
Vi-syneral®* and 100 meg. of B12 hypodermically
daily for 14 days) serves as a therapeutic test. If

* Multivitamin and mineral preparation.

this is successful, oral therapy may be employed.
The vasodilators, Ilidar 25 mg. four times a day
and Prisoline, 80 mg. long-acting every 12 hours,
may he helpful for neuropathy due to ischemia. On
occasion, sympathectomy and large vessel operation
may be necessary. The amount of nerve damage
depends largely upon the cause, duration and sever-
ity of the basic disease.

Night cramps. These are caused often by ischemia,
venous congestion from thrombosis or insufficiency,
peripheral neuropathy, radiculitis, excessive use of
diuretic agents or low sodium diets, poor foot and
back posture, hypocalcemia and pregnancy. Treat-
ment involves correction of the underlying cause.
Diuretics should be discontinued and sodium ad-
ministered, proper arch supporters should be used,
care of veins in the form of elastic stockings or
surgical treatment carried out, and peripheral ar-
terial dilators such as cyclandelate (Cyclospasmol®)
200 mg. at night before bed or nylidrin (Arlidin®,
6 mg. at night) prescribed. Giving quinidine 0.2
gm. with Benadryl® 50 mg. at night is highly effec-
tive except in patients with radiculitis and peripheral
neuropathy. Dicalcium phosphate is helpful in ap-
propriate cases and aluminum hydroxide gel may
help reduce the hyperphosphatemia associated with
cramps of pregnancy.

Raynaud's phenomenon. Primary Raynaud’s dis-
ease attacks young women and is characterized by
periodic vasospastic phenomena of the digits as a
result of nervousness or cold. Secondary Raynaud’s
disease may be associated with Buerger’s disease,
ergotism, diabetes, arteriosclerosis, collagen diseases,
syphilis or other disease states. Conservative ther-
apy generally is superior to thoracic sympathectomy
because of the epinephrine sensitivity and regrowth
of sympathetic nerves after operation. Tranquilizers
such as meprobamate in combination with vaso-
dilators such as Ilidar®, long-acting Priscoline® and
long-acting beta-pyridyl carbinol (Roniacol®) 150
mg. three times a day are helpful. Use of 2 per cent
nitroglycerin ointment locally produces vasodilata-
tion. The cause of the Raynaud’s phenomenon must
be constantly looked for. Examinations should be
made for lupus erythematosus cells, abnormal al-
bumin-globulin ratio, cryoglobulins and hyperglyce-
mia, and should be repeated periodically.

Acute arterial thrombosis of small vessels. Throm-
bosis of vessels at or distal to the popliteal or brach-
ial arteries may be treated with intravenous heparin
and intra-arterial fibrinolysin. Intra-arterial Pris-
coline®, 25 mg., dilates collateral circulation and
passes into the general circulation slowly because
of the arterial obstruction. Intravenous alcohol pro-
duces vasodilatation and sedation.

156

CALIFORNIA MEDICINE

Peripheral arterial emboli are usually treated
surgically as soon as possible, especially if they are
proximal to the brachial or popliteal arteries. Some
of the measures listed under arterial thrombosis in
a preceding paragraph are employed concomitantly.

Abdominal aneurysms. Medical treatment involves
rest and the maintenance of a moderately low blood
pressure. Surgical therapy is indicated if the an-
eurysm is large, expanding or leaking (as may be
indicated by periodic backaches). A vicious cycle is
established by an expanding blood vessel, for the
greater the diameter the greater the tension of the
vessel wall and the greater the possibility of rupture.

Ulceration and gangrene. Conservative treatment
of ulceration of the skin involves debridement and
drainage, a combination of dilator drugs, including
alcohol. Ilidar® and Priscoline®, cultures to identify
the organisms, sensitivity tests and appropriate anti-
biotics locally and orally. Large vessel surgical
operation and sympathectomy may be necessary to
promote healing. Gas gangrene antitoxin is given if
the ulceration and gangrene are extensive.

DISCUSSION

It is apparent that vasodilators must be selected
intelligently for the treatment of patients with
peripheral vascular diseases so that vasodilatation
will be produced in the tissue in which it is needed.
The following therapeutic principles should he fol-
lowed: Cutaneous vasodilators are used in Raynaud’s
disease and as an aid in healing skin ulcers or re-
tarding atrophy of the skin. Muscle dilators are used
for ischemic night cramps, muscle atrophy and inter-
mittent claudication.

The choice of a drug for the treatment of periph-
eral vascular disease has become more difficult with
the increased number of drugs available and it is nec-
essary to understand the way drugs modify the pe-
ripheral circulation. A most important yardstick for
judging the efficacy of a drug is probably simple ob-
servation by the physician and the subjective report
of the patient, but objective measurements should be
used also. However, in view of the impracticability
of trying all the available drugs on all patients, the

primary choice should he based on objective funda-
mental physiologic considerations.

Although it is customary to classify peripheral
vascular diseases as organic (occlusive) or func-
tional (spasm or vasoconstriction) it is rare that
any clinical entity will fall into either category
exclusively. Rational therapy for these two basic
situations is distinctly different. Disorders producing
organic occlusion respond to procedures which di-
rect blood around the occluded area by opening
collateral vessels or remove the occlusion by surgical
or possibly by enzymatic action. In contrast, treat-
ment of functional circulation abnormalities involves
dilatation of vessels by release of excessive vasocon-
strictor tone or by other appropriate means. Because
of the association of the two types of disorders, it
becomes important to assay the relative importance
of each. It is therefore necessary to analyze each
case carefully to determine the proper course of
treatment. One should remember that altered vas-
cular reactivity of vessels to stimuli or drugs may
occur in various disease states such as pheochromo-
cytoma, etc., and therefore careful clinical studies
are required before drugs are administered. The
possibility of diversion of blood away from a dis-
eased area by drugs should be borne in mind. Also,
combined therapy is usually advisable for the treat-
ment of peripheral vascular diseases employing
drugs which have different sites of action in order
to produce additive effects.

The medical care of patients with peripheral
arteriosclerosis involves long term follow-up treat-
ment by the internist. It is often advisable to increase
the circulation locally by surgical operation — for
example, with thromboendarterectomy or a sym-
pathectomy— and at all times close cooperation with
the surgeon is mandatory. Usually the work of the
surgeon is short-term and does not involve the total
care of the patient and his numerous problems.

4041 Wilshire Boulevard, Los Angeles 5.

REFERENCE

1. Hyman, C., and Winsor, T.: Blood flow redistribution
in the human extremity; the diversion phenomenon, Am. J.
Cardiology, 4:566, Nov. 1959.

VOL. 97, NO. 3 • SEPTEMBER 1962

157

Appendicitis and Pregnancy

RUTH M. KING, M.D., and GAIL V. ANDERSON, M.D., Los Angeles

Appendicitis in a pregnant or a postpartum patient
is a serious problem. Diagnosis is difficult in these
conditions and delay in diagnosis and definitive
therapy may have severe consequences for mother
and fetus.

Studying the problem is beset with obstacles.
True incidence is difficult to determine from hos-
pital records, for in some cases appendicitis may
be suspected but the diagnosis not recorded unless
the patient is taken to surgery and in others the
diagnosis may have been entertained but not re-
corded because another condition was found at
laparotomy. This tends to limit the data on incidence
to cases in which a clinical diagnosis of acutely
inflamed appendicitis is confirmed at operation.

METHOD AND MATERIAL

In the present study, the clinical charts of all
patients at the Los Angeles County General Hospital
with diagnosis of pregnancy and appendicitis be-
tween 1957 and 1961 were reviewed. During this
five-year period, there were approximately 56,000
deliveries and 18,000 nonterm pregnant patients
admitted. Within this group, there were 36 cases of
clinically diagnosed acute appendicitis, an incidence
of 0.05 per cent. Twenty -nine patients were ante-
partum at the time of diagnosis and seven were
within six weeks postpartum. Appendectomy was
carried out in 35 of the patients. One patient had
ovarian cystectomy only and three others had ovar-
ian cysts removed as well as the appendix. Diagnosis
was confirmed hy microscopic examination in 21
of the antepartum patients and in six out of the
seven postpartum patients. Clinical accuracy in di-
agnosis was 75 per cent (Table 1) .

The age range of the patients was 18 to 40 years,
the majority being in their twenties. The parity of
these women also was of wide range — zero to 15,
the majority being one to four. Two cases occurred
in the first trimester, 11 in the second, and 16 in
the third.

Since there is much discussion as to the difficulty
of making a diagnosis of appendicitis in pregnancy,
we analyzed the frequency of the classical signs and

From the Department of Obstetrics and Gynecology, University
of Southern California, and Los Angeles County Hospital, Los
Angeles.

Presented before the Section on Obstetrics and Gynecology at the
91st Annual Session of the California Medical Association, San
Francisco, April 15 to 18, 1962.

• In 74,000 obstetrical patients at Los Angeles
County Hospital the incidence of acute appen-
dicitis in pregnancy was 0.05 per cent. In a
study of 36 cases of clinically diagnosed appen-
dicitis in pregnancy between 1956 and 1960, it
was shown that the fetal and maternal morbid-
ity and mortality were decreased when a defi-
nite operative procedure was done early. The
difficulty in diagnosis is increased by the neces-
sary consideration of pyelonephritis and twisted
ovarian cyst. Rupture of the appendix increased
hazards to maternal and fetal survival. It was
noted also that threatened premature labor may
indicate a ruptured appendix. Emergency oper-
ation with the use of antibiotics in such cases
was effective therapy. The incidence of prema-
ture delivery was proportionate to the delay in
operating. If operation was performed in less
than eight hours after admission to the hospital,
there was no maternal or fetal loss. A delay
greater than eight hours resulted in a 17 per
cent fetal loss in premature delivery and 4 per
cent fetal loss of infants at term.

symptoms of appendicitis. The chief complaint of
the patients was abdominal pain, the pain generally
beginning in the upper abdomen and shifting to the
right lower quadrant, with associated anorexia,
nausea and vomiting (Table 2). Eleven patients,
however, did not have shifting pain — only localized
pain in the right lower quadrant. Several others
emphasized radiation of the pain to the right flank.
Less than half the patients were constipated. All
patients in this series had right lower quadrant
tenderness, although the point of maximum tender-
ness varied according to the length of gestation.
The majority also had rebound tenderness, right-
sided tenderness on rectal examination, and de-
creased bowel sounds. Only eight patients had posi-
tive psoas and Rovsing’s sign.

During pregnancy, increased leukocyte content
that does not go above 12,000 per cu. mm. of blood
is not considered indicative of infection.6 Seven
patients in the present series with an inflamed ap-

TABLE 1. — Incidence of Appendicitis in Pregnancy and the
Puerperium, Los Angeles County Hospital, 1957-7961.

Total obstetrical patients 74,000

Total with clinical diagnosis of

appendicitis* 36 0.05%

Antepartum 29

Postpartum 7

Appendectomy performed 35

‘Diagnosis confirmed by pathology in 27 cases — 75 per cent.

158

CALIFORNIA MEDICINE

TABLE 2. — Presenting Symptoms and Signs of 29 Pregnant Patients with Clinical Diagnosis of Appendicitis.

Diseased Appendix
21 Canes

Number Per Cent

Norma

Numbei

il Appendix
Cases

• Per Cent

Abdominal pain shifting to RLQ

57%

12%

Right lower quadrant pain only

38%

Pain in RLQ radiating to flank

38%

Nausea and vomiting

76%

75%

Anorexia

62%

Constipation

33%

12%

Fever

19%

12%

Right lower quadrant tenderness

100%

Rebound tenderness

71%

38%

10.

Rectal tenderness on the right

67%

62%

11.

Decreased bowel sounds

52%

38%

12.

Temperature > 100°

48%

25%

13.

Positive Psoas and Rovsing signs

29%

25%

pendix had a leukocytosis below that level and 14
patients had a count greater than 12,000 per cu.
mm. In two patients with a normal appendix leuko-
cytes numbered fewer than 12,000 per cu. mm. and
in six patients it was greater than 12,000. In only
one patient, whose appendix was ruptured, did leu-
kocytes exceed 20,000 per cu. mm.

The postpartum patients were consistent only in
the complaint of pain in the right lower quadrant
of the abdomen, confirmed as tenderness in this area
by the examining doctor. The accompanying symp-
tom most commonly present was anorexia. In addi-
tion only half of the patients had fever, vomiting,
constipation or urinary symptoms. In all cases the
differential diagnosis was between acute appendi-
citis and acute salpingitis. Four patients had definite
right adnexal tenderness and three others had a foul
cervical discharge, but all of them also had an in-
flamed appendix. The one patient whose appendix
was normal and who had right unilateral acute sal-
pingitis, had no adnexal tenderness, but was ex-
quisitely tender at McBurney’s point. She was three
days postpartum at the time the symptoms developed.
In all but one postpartum patient, the leukocytes
numbered more than 12,000 per cu. mm.

TREATMENT

The primary treatment of these patients was
surgical. Whenever the diagnosis of acute appendi-
citis was definitely made on clinical grounds or
could not be ruled out as the cause of persistent
pain in the right lower quadrant of the abdomen,
operation was scheduled as an emergency.

The abdomen was opened through a high right
transverse muscle-splitting incision in 31 cases, and
through a right paramedian incision in five cases.
In all but one case the appendix was removed re-
gardless of its gross appearance. In one instance a
right ovarian parasitic dermoid cyst was found and
the appendix, which was observed to be normal,

VOL. 97, NO. 3 • SEPTEMBER 1962

was not removed. Although the appendix appeared
normal in several cases, microscopic examination
showed acute inflammation. In no case was the
pregnancy terminated concomitantly by cesarean
section.

As a prophylactic measure, ancillary antibiotic
therapy — with penicillin and streptomycin or achro-
mycin— was begun preoperatively in all cases of
suspected ruptured appendicitis, in all postpartum
patients, and in half of the second and third tri-
mester patients. If pronounced suppuration or
definite rupture of the appendix was observed at
laparotomy, intravenous administration of antibi-
otics was begun immediately.

Progesterone was used in both of the patients
operated upon in the first trimester, in six of
eleven in the second trimester and in seven of
16 third trimester patients. Neither of the first
trimester patients showed any signs of threatened
abortion, nor was there any indication of a re-
lationship between the administration of proges-
terone and early delivery in the second trimester
patients. Of the third trimester patients, those
who received progesterone showed a greater ten-
dency to go into premature labor than those who
did not receive it. However, progesterone was not
thought to be significant in precipitating premature
labor.

MATERNAL AND FETAL OUTCOME

The seriousness of appendicitis in pregnancy is
reflected in both maternal and fetal outcome, and
can be directly related to the rapidity with which
the above therapeutic regimen is carried out (Table
3). A period of eight hours was arbitrarily selected
as a reasonable time to make the definite diagnosis
of appendicitis and get the patient to the operating
room. The patients who were operated upon within
eight hours after admission to the hospital had few
postoperative complications. In patients who went

159

longer before operation, morbidity, including fever,
ileus, urinary tract infection or wound infection
was twice as common.

There was one maternal death. The patient. 36
weeks pregnant, entered the hospital after two days
of abdominal pain, at first about the umbilicus and
later shifting to become localized in the right lower
quadrant. Pronounced right lower quadrant tender-
ness was present. The uterus was irritable, the cervix
undilated. Fetal heart tones were strong and regular.
Threatened premature labor, silent placenta abruptio
and acute appendicitis were considered. Twenty
hours after admittance to hospital a diagnosis of
ruptured appendix was made and operation was
promptly done. Widespread peritonitis had resulted
from ruptured suppurative appendicitis. Three days
after operation the patient became febrile, uremic
and jaundiced and the abdomen was distended. She
was delivered of a term stillborn infant on the
fourth day and died on the fifth postoperative day.
At autopsy, peritonitis, acute tubular necrosis of the
kidneys and pronounced fatty changes in the liver
were noted.

Both patients whose appendix was removed dur-
ing the first trimester were delivered of living in-
fants at term. Six of 11 patients operated upon in
the second trimester and seven of 16 in the third
trimester had premature delivery. Sixty-two per cent
of these premature deliveries occurred within the
first four postoperative days and thus must be
considered to be related to the appendicitis and the
operative procedure in the mother.

No patient in whom operation was done within
the eight-hour period lost her baby. In the group of
patients in whom operation was delayed, four had
stillborn infants and one a premature infant who
died in the neonatal period. Fetal heart tones had
been heard in all patients who later were delivered
of a stillborn infant. Thus total fetal loss in patients
with delayed operation was 17 per cent. Three of
the five infant losses occurred in patients with
ruptured appendix.

Postoperative maternal morbidity and fetal loss
was greater in patients with a perforated appendix
than in the remainder of the group (Table 4).

DISCUSSION

A survey of the previous reports on appendicitis
in pregnant women shows that most observers be-
lieve this to be a distinct and serious problem.7 9,10
This opinion has recently been challenged by Bas-
sett1 who expressed belief that the disease is not much
different in pregnant than in nonpregnant patients.

The incidence of 0.05 per cent in the present
study is somewhat lower than that given by other

TABLE 3. — Relationship Between Delayed Operation, Maternal
Morbidity, and Fetal Loss in 29 Antepartum Patients.

Less Than
8 Hours Delay

More Than
8 Hours Delay

Maternal morbidity

.... 4

Maternal mortality

.... 0

Premature delivery :

Living — Discharged well

.... 3

Living — Neonatal death

.... 0

Stillborn

... O'

Percentage fetal loss

.... 0

r— 1

Term delivery:

Living — Discharged well ....

.... 8

Living — Neonatal death

.... 0

Stillborn

.... 0

Percentage fetal loss

investigators2,4 — 0.1 per cent to 0.17 per cent. Our
figure almost certainly would have been higher if all
cases of right lower quadrant abdominal pain in
which the diagnosis was considered could have been
included in this series. The incidence of pregnancy
in women with appendicitis is 2 per cent.2

Clinical accuracy in diagnosis — with both the
obstetrical and surgical staff agreed upon the diag-
nosis and operative therapy — was 72 per cent in the
present series (Table 1). This is higher than the
42 per cent reported by Bryan3 and 50 per cent by
Dickison.5

A wide range is also found in the literature when
the incidence of appendicitis is related to the stage
of gestation. Black2 noted no difference between one
trimester and the next; Burwell4 found it three times
more common in the first than in the third trimester,
and Dickison0 reported 70 to 80 per cent in the first
six months. The majority of the patients in the pres-
ent series were in the third trimester.

Most patients with appendicitis — especially in the
first six months of pregnancy — present the classical
findings of abdominal pain shifting to the right
lower quadrant, accompanied by anorexia, nausea
and frequently vomiting and constipation. Even
though, later in pregnancy, the point of maximum
tenderness shifts upward and lateral from McBur-
ney’s point, there is still definite right lower quad-
rant tenderness. Rebound tenderness and rectal
tenderness high on the right side are additional
diagnostic signs present in well over half the cases.

Leukocytes may number as many as 12,000 per
cu. mm. in normal pregnancy.6 Twice as many of
the patients in the present series had counts greater
than 12,000 as had counts less than 12,000. In cases
in which leukocyte count was done more than once
before operation there was a moderate rise between
the earlier and the later. This increasing count is
considered by some investigators8 to be the only
reliable laboratory aid. A leukocyte count greater
than 20,000 does not necessarily indicate peritonitis.

160

CALIFORNIA MEDICINE

TABLE 4. — Outcome of 5 Coses of Perforated Appendix.

Weeks

Gestation

Diagnosis/Labor

Abruptio

Surgical

Delay

Maternal

Morbidity

Maternal

Mortality

Delivery

Case 1

7 hours

Term

3 hours postoperative
Living child

Case 2

56 hours

Premature

2 hours postoperative
Living child

Case 3

22 hours

Term

4 days postoperative
Stillborn

Case 4

13 hours

Premature
2 days postoperative
Neonatal death

Case 5

20 hours

Premature

2 hours postoperative
Stillborn

Nor is the converse true: In only one case of five
did the leukocyte content exceed 20,000 per cu. mm.
of blood in patients with a ruptured appendix.

DIFFERENTIAL DIAGNOSIS

The differential diagnoses to be considered in
antepartum cases are primarily pyelonephritis,
twisted ovarian cyst and the round ligament syn-
drome. Especially in the second and third trimesters,
the most difficult distinction is between appendicitis
and pyelonephritis. Appendicitis was considered in
all cases. Pyelonephritis was considered in 16 of 36.
In pregnancy the enlargement of the uterus displaces
the appendix upward and laterally,2 thus shifting
the pain of appendicitis to a higher point. This
causes frequent discomfort in the right flank and
radiation to the right costovertebral angle area. It
is this finding of right flank and back tenderness
with a few white blood cells in the catheterized
urine specimen that leads to confusion. The sig-
nificance of a small number of white cells in repeated
analyses of the urine is difficult to evaluate. This
finding may be due to local reaction around the
ureter from a retrocecal appendix; or there may
be no abnormalities in the urine in the presence of
pyelonephritis with right ureteral obstruction and
hydronephrosis. An intravenous pyelogram may be
necessary to make the distinction.

Twisted ovarian cysts may also rise out of the
pelvis with advanced pregnancy, but they should be
readily palpable. Cysts lying out of the true pelvis
will produce pain high in the right lower quadrant
of the abdomen. Even though in none of our cases
was there a right lower quadrant mass palpable, this
diagnosis was considered in 40 per cent of the cases.
Small subserous fibroids may become infarcted dur-
ing pregnancy and become painful, but are usually
palpably connected to the uterus.

The possibility of round ligament syndrome was

VOL. 97, NO. 3 • SEPTEMBER 1962

mentioned in four cases. The stretching of the round
ligament and the enlarging of broad ligament varices
may cause significant pain in the right lower quad-
rant of the abdomen, especially in the presence of
dextrorotation of the uterus. However, pain on this
basis has no accompanying gastrointestinal symp-
toms and is usually readily relieved by rest and
position change.

If one is considering the possibility of acute
appendicitis in a woman in the third trimester, and
on examination of the abdomen he feels an irritable
uterus, suggesting threatened premature labor, the
appendix may have already ruptured. Generalized
tenderness is not always present in these circum-
stances. Threatened premature labor or abruptio
placenta was considered in four of five patients
with a ruptured appendix in the present series. Due
to the large contractile mass of the uterus, infection
is not manifest as a localized abscess and peritoneal
irritation from the wider inflammatory reaction may
be the initiating factor in premature labor.2

In the first trimester, the possibility of ectopic
pregnancy must be considered. Although the uterus
may be enlarged, an adnexal mass and tenderness
are present in ectopic gestation. In one of the cases
in the present series the patient was put in hospital
the week before laparotomy for observation because
of pain in the right lower quadrant of the abdomen
and was discharged with the diagnosis of possible
unruptured ectopic pregnancy. At operation a rup-
tured right ovarian cyst was seen and the appendix
was normal. As uterine enlargement in this case had
not displaced the appendix, the tenderness was at
McBurney’s point.

In the postpartum period, diagnostic considera-
tion has to be given to the possibility of salpingitis.
A past history of pelvic infection and the presence
of foul-smelling heavy vaginal discharge as well as
true adnexal tenderness are helpful points in dis-
tinguishing this disease from appendicitis. After-

161

birth pain, noted as a factor in some cases by
Burwell and Brooks,4 was not a consideration in any
of the cases in the present series.

Prompt operation is the key to successful therapy.
One cause of delay is that the patient may be slow
to seek medical attention, attributing the pain to the
general discomfort of pregnancy. Also, the physician
may hesitate to operate during pregnancy, fearing
abortion or premature delivery. In this regard it
must be borne in mind that surgical operation has
been shown to have no effect, per se, on gestation.13

The present study seemed to indicate an eight-
hour limit in which to make a definitive diagnosis
and carry out operation. If a definitive diagnosis
and decision for operation was not made within this
eight-hour limit, the tendency in most cases was to
extend the delay to 24 or more, which w7as danger-
ous to mother and fetus. Hence successful treatment
of appendicitis in pregnant women requires prompt
diagnosis and immediate surgery for maximum ma-
ternal and fetal survival.

1200 North State Street, Los Angeles 33 (King).

REFERENCES

1. Bassett, J. W.: Appendicitis in pregnancy, Amer. J.
Obstet. Gynec., 82 :828-832, Oct. 1961.

2. Black, W. P.: Acute appendicitis in pregnancy, Brit.
Med. J., 1:1938-1941, June 1960.

3. Bryan, W. M.: Surgical emergencies in pregnancy and
in the puerperium, Amer. J. Obstet. Gynec., 70:1204-1213,
Dec. 1955.

4. Burwell, J. C., and Brooks, J. B.: Acute appendicitis
in pregnancy, Amer. J. Obstet. Gynec., 78:772-775, Oct.
1959.

5. Dickison, J. C. : Acute appendicitis complicating preg-
nancy, Canad. Med. Assn. J., 74:367-370, March 1956.

6. Eastman, N. J.: Williams Obstetrics, Appleton-Century-
Crofts, Inc., N. Y., 1956.

7. Hoffman, E. S., and Suzuki, M.: Acute appendicitis in
pregnancy, Amer. J. Obstet. Gynec., 67:1338-1350, June
1954.

8. Priddle, H. D., and Hesseltine, H. C.: Acute appen-
dicitis in the obstetric patient, Amer. J. Obstet. Gynec.,
62:150-155, July 1951.

9. Renn, C. A., Douglas, L. P., and Cushman, G. F.:
Perforative appendicitis with generalized peritonitis and
pregnancy at term, Amer. J. Obstet. Gynec., 62:1343-1346,
Dec. 1951.

10. Schelpert, J. W., Ill: Acute appendicitis in the obstet-
rical patient, New York J. Med., 61:4032-4035, Dec. 1961.

162

CALIFORNIA MEDICINE

Cancer Therapy

Evaluation of Supervoltage X-Ray — A Review of the Literature

LEWIS G. JACOBS, M.D., Palo Alto

At its forty-first annual meeting in December
1955 the Radiological Society of North America held
a symposium on supervoltage therapy* 1 2 3 4 5 6 7 8 to evaluate
the further role of 250 kv. therapy. The discussants
did not favor junking this modality. While not com-
plete, evidence as to whether supervoltage therapy is
better than 250 kv. therapy would seem to be worth
evaluation.

There is no question that proportionally the depth
dose as measured physically is greater in the super-
voltage than in the orthovoltage range. But the
meaning of this larger figure when evaluating the
effect of supervoltage in curing cancer is not clear.

The results of radiotherapy depend on a very
complex set of circumstances. The higher depth dose
may and in fact in some cases does produce severe
damage to structures in its path about the tumor,
and the assumption that a greater number of cures
will result because of dose increase must be bal-
anced against the well documented fact, established
by the French school of radiologists about 25 years
ago, that severe damage to the tumor bed lessened
rather than increased the proportion of cures. In
any event, a different “dose” is only meaningful if
more “cures” result.

In order to evaluate this point, two forms of can-
cer were selected for review. Cancer of the tonsil
was chosen as an example of a relatively accessible
tumor, and cancer of the ovary as an example of
deep seated disease. All conveniently available arti-
cles found in the literature were reviewed and a
list was made of the number of cases treated, the
number of five-year survivals, and the voltage range.
Articles not stating the voltage were not excluded,
nor were cases treated with teleradium excluded.
The data thus completed were checked by analysis
of variance for the significance of the distribution.
In both cases (Tables 1 and 2) the groups were
random, with about 0.5 per cent chance of a sig-
nificant variation. In simple language, this means
that all cure rates in the groups are identical, differ-
ing only because of the accidents of sampling. In
order to make this visually evident, data on the two
groups were graphically plotted, each cure rate and
its standard deviation being given in order of as-

Submitted October 13. 1961.

• Statistical evidence is presented to suggest that
cure rates achieved by supervoltage are not sig-
nificantly different from those achieved by or-
thovoltage in carcinoma of the tonsil and of the
ovary.

cending magnitude. Each rate was coded to indicate
voltage. These graphs (Charts 1 and 2) well show
the random distribution of the voltage keys. In fact,
supervoltage tends to fall in the middle register of
one and in the lower register of the other graph.

While there is undoubtedly considerable variance
from report to report with regard to distribution of
material, this last observation would appear to me
to raise serious question as to the possibility of a
real difference being obscured. Although this is
strictly true of only the two diseases studied, I can
see no reason to believe that they are different from
other forms of cancer in this regard.

Since this evidence would suggest that the in-
creased cost of supervoltage is not associated with
better cure rates, I believe that we should direct our
endeavor to more profitable areas. Whether the 200
mev range has more to offer, or whether we have
exhausted the possibilities of improved therapeusis
by voltage increase, I cannot pretend to answer.

Veterans Administration Hospital, Palo Alto.

REFERENCES

1. Berven, E. G. E.: Development of technique and results
of treatment of tumors of the oral and nasal cavities. Am.
J. Roentg., 28:332-343, Sept. 1932 as cited in reference (18).

2. Carpender, J. W. J., Cantril, S., Friedman, M., Gutt-
man, R. J., and Watson, T. A.: Supervoltage; should we
junk 250 kv. A symposium, Radiol., 67:481-515, Oct. 1956.

3. Chu, F. H. C.: The results of treatment of ovarian can-
cer with one million volt x-ray, S. G. 0., 104:42-52, Jan.
1957.

4. Clifton, R. B., and Harden, J. C.: Carcinoma of the
mouth. Am. J. Surg., 92:894-898, Dec. 1956.

5. Coutard, H. : Roentgen Therapy of Epitheliomas of the
tonsillar region, hypopharynx, and larynx from 1920 to
1926, Am. j. Roentgenol., 28:313-331, Sept. 1932 as cited
in reference (18) .

6. Dancot, H.: Treatment of epitheliomas of the palatine
tonsil by x-ray, J. de Radiol, et Electrol., 36:24-33, 1955.

7. Ennuyer, A., and Bataini, J. P. : Tumors of the tonsil
and velopalatine region, Masson et Cie., Paris VP, 1956.

8. Friedman, Milton, Southard, M. E., and Ellett, W.:
Supervoltage (2 mev) rotation irradiation of carcinomas of

VOL. 97, NO. 3 • SEPTEMBER 1962

163

TABLE 1. — Data from the Literature on 5-Year Arrests of Carcinoma of Tonsil

Author

Kv.

Used

Number

Treated

5-Year

Survival

X/N

5-Year

Survival

Per Cent

X2/N

Berven1

23.9

121

4.8435

Clifton & Harden4

5.3

.0526

Coutard5

180

32.3

441

6.7846

Dancot6

180-200

15.7

196

2.2225

Ennuyer & Bataini7

534

18.0

9216

17.2584

Friedman and coworkers8

. 2000

8.3

.0833

Maier15

Ra.

25.5

144

3.0626

Martin & Sugarbaker16

200-250

157

16.6

676

4.3058

Parschall & Stenstrom18

200-220

26.2

484

5.7619

Scanlon and coworkers10

43.5

400

8.6956

Schall-0

. 190

5.3

.2133

Schonbauer22

Ra.

104

12.5

169

1.6250

Sheline, Jones & Morrison28

200

16.0

.6400

Sheline, Jones & Morrison23

1000

18.2

.3636

Teloh25

142

5.0

.3465

Walker & Schultz26

200

5.6

.0556

Walker & Schultz26

1000-2000

23.8

1.1905

Total

57.5053

1495

260

17.4

2602

= 45.2174

1495

Difference.

12.2879

S2 = 12.2879 16 = 0.7680

X2 =

= .7680

.1437 =

5.3444

S2 = .174 X .826 4 0.1437
vv

K =
P —

-2.480

0.9934

TABLE 2. — Data from the Literature on 5-Year Arrest of Carcinoma of Ovary

Author

Kv.

Used

Number

Treated

5-Year

Survival

X/N

Per Cent
5-Year
Survival

X2/N

Chu3

1000

112

25.8

841

7.5089

Henderson & Bean0

265

18.1

2304

8.6943

Holmes & Schulz10

1200

24.0

1.4400

Holme11

138

35.5

2401

17.3985

Jacobs & Stenstrom12

200

35.5

121

3.9023

Javert & Rascoe13

30.5

324

5.4915

Kerr & Elkins14

200

190

30.5

3364

17.7053

Munnell, Jacox & Taylor17

180

200

27.5

3025

15.1250

Munnell, Jacox & Taylor17.

250

148

27.9

1681

11.3581

Schmitz & Majewski21

800

143

20.3

841

5.8811

Sisson & Garland24

200

135

20.0

729

5.4000

Wheelock and coworkers27

27.1

169

3.5208

Total

103.4258

3842

Summation All Cases

1494

384

25.7

1494

= 98.6988

Difference

4.7270

S2 = 4.727 h- ii = 0.4297

X2 =

= .4279 ^

.201 = 2.1378

K =

— 2 8191

S2 = 0.257 X 0.743 = 0.201

P =

0.9976

Code for Tables 1 and 2:

Under heading "kilovolts used": N. — not stated; H. — "High voltage" not stated exactly; Ra. — radium bomb
teletherapy. The first two of these should be considered in the orthovoltage range, the third supervoltage.

Under the calculations, "K" is calculated by the following formula:

K =

9 ( n — 1 )

where n is the number of lines in the table.

164

CALIFORNIA MEDICINE

Chart 1. — Results of radiotherapy in carcinoma of the
ovary.

Chart 2. — Results of radiotherapy in carcinoma of the
tonsil.

the head and neck, J. Am. Roentgenol., 81:402-419, March
1959.

9. Henderson, D. N., and Bean, J. L. : Results of treat-
ment of primary ovarian malignancy, Am. J. Obs. & Gyn.,
73 :657-661, March 1957.

10. Holmes, G. W., and Schulz, M. D.: Supervoltage radi-
ation, Am. J. Roentgenol., 55:533-554, May 1946.

11. Holme, G. M.: Malignant ovarian tumors, J. Fac.
Radiol., 8:394-401, Oct. 1957.

12. Jacobs, L. G., and Stenstrom, K. W.: Carcinoma of
the ovary, Radiol., 28:725-730. June 1937.

13. Javert, C. T., and Rascoe. R. B.: Serous cystadeno-
carcinoma of the ovary, S. Clin. N.A., 33:557-584, April
1953.

14. Kerr, H. D., and Elkins, H. B.: Carcinoma of the
ovary, Am. J. Roentgenol., 66:184-189, Aug. 1951.

15. Maier, E.: Radium treatment of carcinoma of the
tonsil, Radiol. Austriaca, 1:77-83, 1948.

16. Martin, H., and Sugarbaker, E. L.: Cancer of the ton-
sil, Am. J. Surg., 52:158-196, April 1941.

17. Munnel, E. W., Jacox, H. W., and Taylor, H. C.:
Treatment and prognosis in cancer of the ovary, with a
review of a new series of 148 cases treated in the years 1944
to 1951, Am. J. Obs. & Gyn., 74:1183-1200, Dec. 1957.

18. Parscliall, D. B., and Stenstrom, K. W.: Malignant
lesions of the tonsil, Radiol., 60:564-572, April 1953.

19. Scanlon, P. W., Gee, V. R., Erich, J. B., Williams,
H. L., and Woolner, L. B.: Carcinoma of the palatine tonsil,
Am. J. Roentgenol., 80:781-786, Nov. 1958.

20. Schall, L. A.: Carcinoma of the tonsil, N.E.J.M., 211:
997-1000, Nov. 29, 1934.

21. Schmitz, H. E., and Majewski, J. T.: End results in
the treatment of ovarian carcinoma with surgery and deep
x-irradiation, Radiol., 57 :820-825, Dec. 1951.

22. Schonhauer, I.: On carcinoma of the tonsil, Strahlen-
therapie, 69:121-127, 1941.

23. Sheline, G. E., Jones, M. D., and Morrison, L. F. :
Radiation therapy for cancer of the tonsil, Am. J. Roent-
genol., 80:775-780, Nov. 1958.

24. Sisson, M. A., and Garland, L. IT: Cancer of the
ovary, Stanford Med. Bullein, 15:191-196, Aug. 1957.

25. Teloh, H. A.: Cancer of the tonsil, Arch. Surg., 65:
693-701, 1952.

26. Walker, J. H., and Schulz, M.: Carcinoma of the
tonsil. Radiol., 49:162-168, Aug. 1947.

27. Wheelock, F. C., Fennell, R. H., and Meigs, J. V. :
Carcinoma of the ovary, N.E.J.M., 245:447-449, Sept. 20,
1951.

VOL. 97, NO. 3

SEPTEMBER 1962

165

The Enigma of Circulating Malignant Cells

FELICIANO M. PEREZ, M.D., San Francisco,
and ROBERT H. YONEMOTO, M.D., Duarte

While it is possible to control early primary solid
malignant neoplasms locally by adequate surgical
ablation, deep irradiation therapy or regional per-
fusion and infusion with chemotherapeutic agents,
some patients so treated still die of metastatic
disease.

Recognizing that these deaths are due to hema-
togenous dissemination, clinical and experimental
investigators have recently intensified their searches
in this area of oncology. Questions that are at pres-
ent being given a good deal of attention are: (1)
The actual presence or positive identification of
malignant cells in the circulating blood; (2) the
ultimate disposition of these cells in the body and the
problem of occult metastasis; (3) the prevention
and control of cell dissemination; and (4) the
current status of curative radical surgical treatment
in the light of accumulating knowledge of these
circulating malignant cells.

They are particularly important at present, for
opinion in the current literature is divided between
proposals for ultraconservative modifications of
conventional radical procedures on one side of the
scale and ultraradical dissections on the other.

1. The Presence and Identification of Cancer Cells
in the Circulation

Under this heading there are three major ques-
tions to clarify: (a) Are all the circulating atypical
or abnormal cells actually malignant emboli? Raker
and associates,23 in studies of specimens of blood
taken from 144 patients, all but nine of whom had
tumors, found only two specimens positive for
malignant cells. Sixty patients were found to have
megakaryocytes, which at first were thought to be
malignant cells. However, accumulating experience
has led to progress in the isolation, preparation and
identification methods.22 (b) Are these circulating
cells viable? Recent clinical investigations18,19 have
proven that cultures could be made from cells re-
covered from the blood of patients with certain
types of malignant lesions, (c) If viable, what is
the clinical significance of their presence? Because
the ultimate survival of a particular patient cannot
be definitely correlated with the presence of cancer

Submitted April 10. 1962.

• There is no doubt that cancer cells do enter
the circulating blood of persons with malignant
lesions. Differentiation of them from other atypi-
cal cells found normally in the bloodstream is
at present being studied.

Investigators have expressed belief that most
of the circulating malignant cells in the early
stages of the disease are destroyed by host re-
sistance. Surviving cells, however, develop into
occult metastatic emboli which may remain
quiescent until host defenses collapse. Clinical
measures for the active control of these dormant
implants have not been evolved as yet.

Inasmuch as the mechanism of host resist-
ance is still beyond clinical comprehension, the
only known way to improve survival rates is the
universal application of practical clinical meth-
ods for preventing iatrogenic disseminations, for
devitalizing malignant cells and for apprehend-
ing emboli that may have left the main lesion
just before surgical operation.

Since it adequately eradicates primary sources
of cell dissemination, conventional radical re-
section is still the treatment of choice for deal-
ing with early solid neoplasms.

cells in the bloodstream, the prognostic significance
of this condition is not well understood. Recently,
however, Roberts and coworkers,24 in a study of
283 patients, noted that the survival rate for patients
in whom “cancer cell showers” were observed during
an operative procedure was one-half that for patients
with blood specimens that were negative for ma-
lignant cells at the time of operation.

2. The Ultimate Fate of Circulating Malignant
Cells in the Body and the Problem of Occult
Metastasis

Willis* 2' in a review of the observations of various
investigators on experimental metastasis, concluded
that many of the tumor cells injected experimen-
tally into the bloodstream perish in the lungs. This
conclusion was based on observations that, after
injection of cells intravenously, tumors did not
always develop in the lungs and degenerated tumor
cells were frequently seen in the pulmonary arterioles.
He also concluded that successful tumor transplants
were obtained only when more than a certain mini-
mum amount of tumor cells were injected, and if the
minimum effective quantity were introduced at in-

166

CALIFORNIA MEDICINE

tervals in divided doses, usually no tumors resulted
in the lungs. Jonasson15 concluded from studies in
rats that the presence of cancer cells in the circu-
lating blood is not always followed later by develop-
ment of metastatic lesions.

Recent experimental findings imply that the liver
also plays a part in the natural defense of the body
against embolic cancer cells. The Fishers8 found
that when they damaged the reticulo-endothelial sys-
tem of the liver, artificially induced hepatic lesions
“took” better; and Chan and coworkers8 found that
hepatic metastasis occurred more often in animals
with artificially damaged livers than in controls.
Fletcher and Stewart,10 in their clinical study of
prehepatic and posthepatic blood cancer cell titers
in lesions of portal-drained organs of the abdomen,
noted that the liver “filtered” cancer cells. The role
of the spleen in the overall defense of the body is
not quite well understood.

Roberts and coworkers,25 isolated cancer cells
from the circulating blood of four of five patients
undergoing diagnostic curettage for endometrial
malignancy. Cutler and coworkers7 in their clinical
studies of 2,331 stage-I cases of endometrial car-
cinoma treated by hysterectomy, noted a 58 per cent
five-year survival rate. Assuming, from the Roberts
report, that cancer cells are disseminated in a high
proportion of cases during preliminary diagnostic
uterine curettage, we can speculate, from Cutler’s
study, that the host defense can cope with embolic
cancer cells in about half of early endometrial
carcinoma cases.

Assuming that a majority of the circulating loose
cells perish in the arterioles of the lungs, in the
liver and in other organs of the body, just what
happens to those cells that survive? From the post-
mortem lung studies of Willis,27 four stages in the
transformation of embolic cells into metastatic
lesions can be defined: (a). Embolic single cells
or clumps of cells within the lumen of end-arterioles;
(b) formation of thrombi around the emboli; (c)
organization of the thrombi for fibrosis culminating
in death of the embolic cells) and formation of
nutrient arterioles with subsequent invasion of the
vascular walls; and (d) extra vascular growth of
surviving implants.

What has been done clinically in attempts to
control the above-mentioned phases? Morales and
coworkers20 used chemotherapeutic agents system-
ically at the time of operation as a prophylactic
measure to control loose cells that may have ex-
foliated a short time before operation or during the
procedure. With regard to thrombotic clumps, cur-
rent experimental studies are encouraging. The
Fishers,9 in their investigations of hepatic metasta-
sis, found that thrombolytic agents, particularly

VOL. 97, NO. 3 • SEPTEMBER 1962

heparin, apparently prolonged the stay of cells in
the circulating blood, thereby possibly extending
the exposure of the cells to the action of natural
host defenses. Whether a feasible plan of therapy
based on fibrinolytic action could be applied clini-
cally as a surgical or chemotherapeutic adjunct
remains to be seen.

THE PROBLEM OF OCCULT METASTASIS

Once the thrombotic clumps develop their own
nutrient arterial supply, they become metastatic
lesions and as such are more difficult to control than
emboli. They may remain clinically occult for un-
predictable periods until some triggering mechan-
ism, yet unclear, provokes them to wild autonomous
growth.

The existence of these systemic occult implants is
the bane of adequate primary surgical resections,
because what may have been deemed as “curable”
may be in actuality just “resectable.” Current stand-
ard methods for clinical detection of these quiescent
autografts, such as pulmonary and skeletal radio-
graphic surveys, intravenous pyelograms or liver
function studies, are admittedly crude and unre-
liable in early cases. Routine bone trephining bi-
opsy, as of the lumbar vertebral spine in breast
tumors,12 or bone-marrow aspiration biopsies as
in sarcomas of the extremities,21 are helpful only
if found positive. Needle biopsy of the lungs or liver
is not clinically applicable routinely for preoperative
screening purposes.

Until bone marrow shielding or sparing tech-
niques can be perfected, total body irradiation or
massive systemic chemotherapy for the control of
occult metastasis cannot be used. The part immuno-
logic processes play in the early stages of neoplastic
diseases is still under intensive investigation. The
benefits derived from the alteration of hormonal
environment by early ablation of the gonads, adre-
nals or hypophyses in the management of hormonally
dependent tumors have not been clarified as yet.

3. The Prevention and Control of Cell Dissemina-
tion

Cancer embolization takes place at various periods
in the course of solid neoplastic diseases:

1. At the preoperative period, by spontaneous
dissemination. Recently. Romsdahl and coworkers,26
found that in two of six patients with resectable
primary melanoma, two had cancer cells in periph-
eral blood specimens before operation. When
regional node dissection was done no microscopic
evidence of nodal involvement was found in one
case whereas in the other case two of thirteen nodes
removed were positive for malignant disease.
Whether this situation holds true in early, less in-

167

tense types of solid neoplasms is still undetermined.
The possible dissemination of cells from early un-
discovered lesions by the pressures and stresses of
normal body motions or by external massage is
beyond control.

2. At the time of diagnostic and operative manip-
ulations. Grove11 and Jonasson and associates111
observed definite relationship between the occur-
rence of cells in the circulating blood and the press-
ing or manipulating done in the course of diagnostic
examination or surgical operation.

3. After the formation of local or regional re-
currences. as well as after the formation of systemic
secondary implants. In most cases of sarcoma of the
limbs, regional and recurrent growths have been
prevented by primary radical ablation. The control
of dissemination in late stages of the disease obvi-
ously offers no benefits.

CURBING IATROGENIC METASTASIS

As a measure for prevention and control of iatro-
genic metastasis, ways have been worked out to
reduce the volume and vitality of potentially escap-
ing tumor cells.

Reducing the Volume of Cells

Cole4 cautioned against the massaging effects
entailed in cleansing the area over palpable tumors
by washing with soap and water. In the future, the
use of antiseptic aerosprays or compresses for this
purpose may become routine.

In dealing with lesions of the extremities, the
use of two tourniquets during preliminary biopsy
procedures, one placed proximal to the tumor and
the other above it, with the proposed site of ampu-
tation between them, as described by Hayles and
coworkers13 is ideal and commendable. With the
tourniquet compression, both the main and collat-
eral venous outlets are kept under control during
the surgical procedures. In addition, cancer cells
dislodged during the excision of biopsy material
would be kept beyond the amputation site.

Ligation of the principal venous outlets in the
early stage of surgical dissection, as described by
Cole5 in colon resections, by Martin17 in routine
radical neck dissections and by Byron and cowork-
ers1 in radical amputations of limbs, tends to
reduce the volume of disseminating cells at the time
of operative manipulations.

Reducing the Vitality of Cells

One method used by some investigators to lessen
the vitality of embolizing cells is the preoperative
introduction of chemotherapeutic agents into the
main nutrient artery of the primary lesion. In
selected cases, Creech and coworkers’1 utilize regional

massive chemotherapeutic perfusions with the help
of an extracorporeal apparatus. Byron and cowork-
ers1-2 introduce the chemicals directly into the artery
that supplies the area of the lesion just before be-
ginning the ablative procedure.

External deep irradiation in therapeutic doses
before surgical extirpation of tumors of the head,
neck and breast has been done for years.

Hoye and Smith14 in studies of mice noted that
when a solution containing cancer cells taken from
the parent lesion and lightly irradiated was injected
parenterally before operation the incidence of pul-
monary metastasis was reduced 90 per cent.

Some two years ago at the City of Hope Medical
Center a pilot study was begun on the use of rapid
massive deep irradiation therapy as an adjunct to
radical amputations for sarcoma of the limbs. A
total dose of 5,000 rads was administered in daily
doses of 1.000 rads for five days, followed on the
seventh day by radical amputation. In addition,
chemotherapeutic agents were infused into the main
nutrient artery of the tumor to devitalize whatever
viable cancer cells remained. Just before infusion,
the main venous outlets were ligated to hold the
chemicals within the affected limb and to keep dis-
seminating cells from getting into the circulation.
Not enough time has passed for an appraisal of the
effect of this combined procedure.

4. The Status of Radical Excision in the Light of
Accumulating Knowledge of Circulating Malig-
nant Cells

Except for most sarcomas and some virulent
forms of carcinoma, comprehensive statistics at
present consistently indicate that five-year survival
rates after conventional early radical extirpation in
most cases of operable lesions of the kind that
progress “stepwise” are very much better than for
untreated cases. Radical resection of early primary
lesions and the regional areas of secondary spread
removes the immediate as well as future sources of
cell embolization, but the extent of radical resection
in either the “stepwise” or the “explosive” types of
tumors should always be determined by the circum-
stances in each case — by the natural history of the
lesion, its metastatic potentialities, the specific bi-
ologic course in the particular patient and by the
size, stage and location of the lesion.

1640 Valencia Street, San Francisco 10 (Perez).

REFERENCES

1. Byron, Jr., R. L., Cronemiller, P. D., Bierman, H. R.,
and Yonemoto, H. R.: Interscapulothoracic amputation
and sacroiliac disarticulation with adjunctive arterial chem-
otherapy, S.G.O., 111:457-463, Oct. 1960.

2. Byron, Jr., R. L., Yonemoto, R. H., Halluer, W. C., and
Bierman, H. R.: Radical mastectomy with arterial regional
chemotherapy, Surgery, 49:681, May 1961.

168

CALIFORNIA MEDICINE

3. Chan, P., McDonald, G. 0., and Cole, W. H.: The role
of hepatic damage on development of the Walker 256 car-
cinosarcoma, surgical forum; clinical Congress 1960. Vol.
XI, p. 55. Chicago: American College of Surgeons, 1960.

4. Cole, W. H.: Recent advances in treatment of the
cancer patient, J.A.M.A., 174:1287-1290, Nov. 1960.

5. Cole, W. H., Packard, D., and Southwick, H. W.:
Carcinoma of the colon with special reference to prevention
of recurrence, J.A.M.A., 155:1549-1553, Aug. 1954.

6. Creech, Jr., 0., Krementz, E. T., Ryan, R. F„ Reemtsma,
K., Windhlad, J. M., and Elliott, J. L. : The treatment of
cancer by perfusion, A.M.A. Arch. Surg., 79:963-975, Dec.
1959.

7. Cutler, S., Ederer, F., Griswold, M. H., and Greenberg,

R. A.: Survival of patients with uterine cancer, Jour, of
N.C.I., 24:519-539, March 1960.

8. Fisher, E. R., and Fisher, B.: Effect of reticuloendo-
thelial interference on experimental metastases, Surgical
Forum; Clinical Congress 1960. Vol. XI, p. 57, Chicago:
American College of Surgeons, 1960.

9. Fisher, E. R., and Fisher, B.: Experimental studies
of factors which influence hepatic metastases. VIII. Effects
of anticoagulants, Surgery, 50:240-247, July 1961.

10. Fletcher, W. S., and Stewart, J. W.: Tumour cells in
the blood with special reference to pre- and post-hepatic
blood, Brit. Jour. Cancer, 13:33-37, March 1959.

11. Grove, W. J., Watne, A., Jonasson, 0., and Roberts,

S. : Vascular dissemination of cancer in children, A.M.A.
Arch. Surg., 78:698-702, 1959.

12. Haagensen, C. D.: Diseases of the Breast, Philadelphia
and London, W. B. Saunders Co., 1956.

13. Hayles, A. B., Dahlin, D. C., and Coventry', M. D.:
Osteogenic sarcoma in children, J.A.M.A., 174:1147-1177,
Oct. 1960.

14. Hoye, R. C., and Smith, R. R. : The effectiveness of
small amounts of preoperative irradiation in preventing the
growths of tumor cells disseminated at surgery, Cancer,
14:284-295, March-April 1961.

15. Jonasson, O.: Factors concerned with the metastatic
potential of circulating cancer cells. Surgical Forum, Clini-

cal Congress 1960, Vol. XI, p. 53, Chicago: Amer. College
of Surgeons, 1960.

16. Jonasson, 0., Long, L., Roberts, S., McGrew, E., and
McDonald, J. H.: Cancer cells in the circulating blood
during operative management of genitourinary tumors, J.
Urol., 85:1-12, Jan. 1961.

17. Martin, LL: Surgery of Head and Neck Tumors, New
York, Paul B. Hoeber Inc., 1957.

18. McDonald, G. O., Chan, P. Y. M., and Cole, W. H.:
Growth in culture of cancer cells recovered from the blood,
Proc. Am. Assoc. Cancer Res., 3:132, 1960.

19. Moore, G. E., Mount, D. T., and Wendt, A. C. : The
growth of human tumor cells in tissue culture. Surgical
Forum; Clinical Congress 1958, Vol. IX, p. 572, Chicago:
Amer. College of Surgeons, 1959.

20. Morales, F., Bell, M., McDonald, G. O., and Cole,
W. H.: The prophylactic treatment of cancer at the time of
operation, Ann. Surg., 146:588-593, Jan. 1961.

21. Pinkel, D., and Pickren, J.: Rhabdomyosarcoma in
children, J.A.M.A., 175:293-298, Jan. 1961.

22. Priutt, J. C., Hilberg, A. W., Morehead, R. P., and
Mengoli, H. F. : Quantitative study of malignant cells in
local and peripheral circulating blood, S.G.O., 114:179-188,
Feb. 1962.

23. Raker, H. W., Taft, P. D., and Edmonds, E. E.:
Significance of megakaryocytes in the search for tumor
cells in the peripheral blood, New Eng. J. Med., 263:993-
996, Nov. 17, 1960.

24. Roberts, S., Jonasson, O., Long, L., McGrath, R.,
McGrew, E. A., and Cole, W. H. : Clinical significance of
cancer cells in the circulating blood: Two- to Five-year
Survival, Annals of Surg., 154:362-371, Sept. 1961.

25. Roberts, S., Long, L., Jonasson, O., McGrath, R.,
McGrew, E„ and Cole, W. H.: The isolation of cancer cells
from the blood stream during uterine curettage, S.G.O.,
111:3-11, July 1960.

26. Romsdahl, M. D., and Potter, J. F. : A clinical study
of circulating tumor cells in malignant melanoma, S.G.O.,
111:675, Dec. 1960.

27. Willis, R.: The Spread of Tumours in the Human
Body, St. Louis: C. V. Mosby Co., 1952, Ed. 2.

VOL. 97

NO. 3

SEPTEMBER 1962

169

Geriatric Rehabilitation

The Challenge and the Goal

DAVID RUBIN, M.D., Pfi.D., Los Angeles

The most serious challenge currently facing med-
icine in Rusk’s2 view, is the increased incidence of
both chronic diseases and chronic disability among
the older segments of the population. In a recent
report by a United States Senate Subcommittee on
Problems of the Aged and Aging, Dr. Rusk is
quoted as saying, “Rehabilitation of the chronically
ill and chronically disabled is not just a series of
restorative techniques — it is a philosophy of medical
responsibility.”

In the United States there are approximately
17.000,000 persons in the age group 65 and over.
Of this number approximately 5 per cent are in in-
stitutions, mostly in long term facilities.3 A recent
study indicates that the proportions of the aged with
one or more chronic conditions range from 74.7 per
cent to 82.0 per cent, depending upon geographic
location.4

In view of the proportionally large and increas-
ing numbers of elderly disabled persons, medical
programs of one kind or another have been de-
veloped and are being developed to meet the existing
and rapidly expanding need. However, the problem
of establishing adequate medical and rehabilitation
services for the aged in the face of personnel short-
age. lack of funds and the passive attitude which
prevails on the part of some physicians and the
community toward the disabled aged is a great one.
As was stated in a report by a committee of the
United States Senate,1 “The ultimate value against
which the several proposed approaches to the prob-
lem should be weighed involves not only the question
of the soundest approach to financing medical care
for the aged; it rests also on the increasing belief
in the possibility of extending human life under
conditions of dignity and creative activity, and using
the best of modern medical science toward this end.”

In this respect it is almost axiomatic that elderly,
disabled patients who might otherwise be rehabili-
tated, at least to some degree, with good medical
care, nursing care and rehabilitation services are
allowed to vegetate and regress physically, emotion-
ally and spiritually. With proper treatment and the

From the Department of Physical Medicine, Mount Sinai Hospital
and Mount Sinai Rehabilitation Hospital, Los Angeles.

Presented before the Section on Physical Medicine at the 91st
Annual Session of the California Medical Association, April 15 to 18,
1962.

® A geriatric rehabilitation program at Mt. Sinai
Rehabilitation Hospital in Los Angeles (which
had been a custodial hospital) demonstrated the
effectiveness of newer methods in rehabilitation
in restoring chronically disabled elderly patients
to a new level of physical, psychological and so-
cial performance.

Efforts to restore morale in patients long re-
signed to invalidism, to make them want to live
socially, to make them useful to themselves
and others and to improve their physical con-
dition brought gratifying and in some cases
dramatic results.

newer knowledge now available it is estimated that
25 to 30 per cent of the elderly patients in institu-
tions could be rehabilitated sufficiently to achieve a
degree of independence consistent with return to
their own homes or to a more socially desirable
climate in a modern boarding home or rest home
facility. That this is not a figment of the imagination
or an idle dream has been demonstrated on a small
scale at the Mount Sinai Rehabilitation Hospital in
Los Angeles.

In January, 1961, an extensive reorganization* of
the Eastside Mount Sinai Hospital or Custodial Care
Home was initiated by action of the executive board
of the Cedars of Lebanon-Mount Sinai Hospitals, a
nonprofit, community-sponsored hospital in Los An-
geles. Until the development of the new program
the facility had served as a custodial and terminal
care center with a 91-bed capacity. A review of the
inpatient population at the outset of the new pro-
gram revealed that almost all the patients were
afflicted with one or more chronic ailments, but
that some were ambulatory and essentially inde-
pendent while others were bedridden and totally
dependent. Between these two extremes were all the
conceivable stages of dependency and chronic phy-
sical disability. In the absence of a true rehabilita-
tion program all patients were potential long-term,
rejected, elderly residents. A few patients had been
“hospital residents” for over twenty years. It was
against this background of long term, custodial,

*The author wishes to acknowledge and to express his appreciation
to Dr. Sidney Soli, associate medical director, Cedars-Sinai Hospital
for his interest and guidance in establishing the rehabilitation program,
and to Mr. Harold Bilsky, administrator, Mount Sinai Rehabilitation
Hospital for his enthusiastic cooperation in the reorganization of the
center.

170

CALIFORNIA MEDICINE

resident care that the hospital administration sought
to establish a rehabilitation program. The stated
purpose of the program was to introduce the newest
methods of rehabilitation medicine in an effort to
restore or maintain every disabled person at the
optimum level of attainable performance — physi-
cally, emotionally, socially and spiritually — so that
he or she may return to a useful and meaningful
place in society.

A GERIATRIC PROGRAM— ITS DEVELOPMENT

The problems inherent in reorganizing an ex-
istent. long-term custodial care facility into a sem-
blance of a modern geriatric rehabilitation center
were many. The need for converting patient and
staff orientation from a static to a dynamic concept
was imperative. The change was required at all
levels of operation, inasmuch as a sedentary, non-
productive and little motivated population was about
to embark on a program of movement and expanded
interpersonal relationships.

As a first step toward improving patient morale
and a sense of wellbeing, it was established that
all wheel-chair and ambulatory patients must dress
in street clothes on arising in the morning. Previ-
ously patients had remained in their night-clothes
from morning to evening and were also fed in their
rooms. The demoralizing effect upon the chronically
disabled patient of remaining in night-clothes
throughout the day is easily surmised. Simultane-
ously, the physical plant was being renovated to
provide for specific areas — therapeutic, as well as
dining, recreational, and social. It was predeter-
mined that all areas should be bright, cheerful,
well-equipped and available to the patients through-
out the day.

The response to communal eating was at first
resisted. Psychologically, the patients in many in-
stances felt ill at ease after months and years of
eating in seclusion, or, at best, with one or two
other persons in the room. However, the embarrass-
ment of eating in the company of three or four
persons at the same table passed, and patients not
originally included soon requested permission to eat
in the newly established dining room. Once the re-
sistance to group eating had been overcome, inte-
gration into social games and other group activities
following the noon meal was a relatively simple
matter. In keeping with the concept that activity
overcomes depression and inertia, scheduled movies,
picnics, parties and outings away from the center
were organized. The many hospital auxiliaries and
their volunteer workers aided in this effort. Once a
favorable physical and social setting to bolster pa-
tient morale, interest and desire had been estab-

VOL. 97, NO. 3 • SEPTEMBER 1962

lished, the stage was set for the heart of the project:
medical rehabilitation.

From a medical rehabilitation standpoint every
patient was examined both by the staff internist and
the physiatrist. Following the examination a reason-
able rehabilitation goal was established, and in-
dividual programs of physical and occupational
therapy were outlined in the presence of the physical
and occupational therapist, either at the bedside or
in the therapy areas. In outlining the programs the
emphasis was placed on functional improvement
through muscle strengthening, restoration of joint
mobility, and self-care training. The latter included
all aspects of dressing, toileting, showering, bath-
ing, feeding and, whenever possible, independent
ambulation. Bedside and bathroom activities of daily
living were carried out in the patients’ rooms and
bathrooms, at first by the occupational therapist and
subsequently with the aid of previously trained ward
personnel under the direct supervision of the thera-
pist. This served to motivate the aids and attendants
who had for years been engaged in dull, routine,
never-changing daily chores. The favorable impact
on the attendant-patient relationship was striking.

Periodically the patient was reevaluated, appro-
priate changes in therapy were made and goals were
reassessed when necessary. Monthly staff confer-
ences were held to review the progress of specific
patients and to correlate the gathered information
from the medical, administrative, nursing, therapy,
social service and dietetic personnel. In this way a
total picture of the patient, his problems, his re-
sponse to therapy, and. ultimately, his placement
was secured. Group participation meetings were
organized in which the rehabilitation patients and
staff personnel, including the nurses and attendants,
took part. In this manner mutual problems are dis-
cussed and solved.

In the course of the first year of operation 56
patients were admitted to the rehabilitation unit,
including 21 custodial patients selected from the
existing hospital census at the initiation of the
program.

RESULTS

The original group of 21 patients selected for
the rehabilitation program ranged in age from 60
years to 82 years. There were 13 with hemiplegia,
two with Parkinsonism, and one in each of the
following diagnostic categories: fractured hip;

rheumatoid arthritis; adult muscular dystrophy;
paraplegia; combined asthma and emphysema: and
unilateral amputation. From this group of so-called
“custodial cases’" a total of four patients were dis-
charged (three returned to their homes and one was
placed in a rest home). Despite the subsequent
return to a custodial status of 11 patients, improve-

1 71

ment was evident in 15 of the 21 patients, and five
became almost completely independent in self care.
Ambulation enough to permit the patient’s walking
to the dining room was achieved in nine cases (in
which previously the patients had been unable or
unwilling to walk ) .

During the first 12 months of operation a total
of 35 new patients, 16 women and 19 men, were
admitted to the rehabilitation center, most of them
in the last six months of 1961. The ages ranged
from 59 to 81 years. Eighteen were hemiplegic, four
had hip fractures, two collagen disease, and one
each of the following: quadriplegia, traumatic

hemiplegia, paraplegia, cerebral aneurysm with hem-
iplegia, asthma and emphysema, osteoarthritis, rheu-
matoid arthritis, cardiac disease, osteomyelitis with
lower extremity weakness, tibial fracture, and above-
knee amputation. These patients were immediately
placed into a program of treatment with an antici-
pated and reasonable goal based on the initial
evaluation. Of this group, 13 were returned to their
homes — seven as partially independent and six as
completely independent in self care. Six patients
were sent to rest homes as partially independent but
in need of continued part-time attendant care. Five
patients were reclassified as custodial, and three died
at the center. The remainder are being continued
in the rehabilitation program. Seventeen of the 35
patients became ambulatory — eight without any
form of support, eight with one cane, one with
crutches.

Twenty-three patients (41 per cent) were dis-
charged from the rehabilitation center in the one-
year period. Considering only the second group of
35 patients, 54 per cent were discharged after three
to nine months of intensive rehabilitation. Of the
56 patients treated during the first year, 42 were
improved by the program.

The following two cases are typical of the im-
provement that was brought about.

REPORTS OF CASES

Case 1. The patient was a 67-year-old man who
was admitted as a direct transfer from the local
county hospital. On April 27, 1961. he had fallen
in the bathroom at a friend’s home and struck his
head on the bathtub rim and then on the floor. He
apparently lost the ability to move his arms and
legs but did not lose consciousness. On admission
to the county hospital he was observed to be alert
and oriented. There was a small laceration over
the forehead and mild suboccipital tenderness of
the neck. Both upper extremities were decidedly
weak, more on the right side than on the left.
Strength in both lower extremities was fair, but the
right leg was weaker than the left. The rectal

sphincter was under good control, but there was
disturbed bladder function. Extensive hypalgesia to
pin prick and hyperactive deep tendon reflexes were
noted. X-ray films of the cervical spine, planograms
of the odontoid process and myelographic examina-
tion on two occasions elicited no evidence of
cervical spine disease. It was assumed that cerebro-
vascular thrombosis had occurred and the patient
showed some improvement in the five weeks he
was in hospital before transfer to the Mount Sinai
Rehabilitation Hospital. The discharge note indicated
that he appeared to improve but could not walk,
despite good return of strength in the lower ex-
tremities, and could not use his upper extremities
in any functional manner.

Upon admission to the center he was observed to
be alert and responsive. He was helped to stand
at the bedside where he showed a spastic standing
posture. He had great difficulty in taking a few
assisted steps. The patient had pronounced spasticity
and weakness of the upper extremities and he could
not use his hands functionally. The lower extremities
were moderately spastic but strength and range of
motion were fair when the patient was supine. The
deep tendon reflexes were hyperactive throughout,
and Babinski and Chaddock signs were present on
both sides. Clonus was observed in both ankles, the
left knee and the left wrist. Sensation was impaired
below the level of the fifth thoracic nerve especially
to pain and temperature. There was an indwelling
Foley catheter. The impression gathered from the
history and examination was that the patient had
partial quadriparesis as the result of injury to the
spinal cord, and that he may have had a cerebro-
vascular accident, leading to the fall and subsequent
cervical trauma.

A program of physical and occupational therapy
was begun immediately. In the course of six months
the patient graduated from bed to wheel chair to
independent ambulation. He developed good use of
his right hand and fair use of the left hand (previ-
ously injured, with loss of three fingers). At first,
spring suspension slings were used to initiate func-
tional movement of the upper extremities and permit
occupational therapy activities. As strength returned
the patient was able to dispense with these devices
and ultimately developed sufficient function to feed,
shave, toilet, and partially dress and undress. At
the time of discharge to his home he was inde-
pendently ambulatory on uneven as well as level
ground, and, except for inability to dress com-
pletely, was independent in self care. Morale and
motivation continued at an excellent level through-
out.

Case 2. An 80-year-old man entered Mount Sinai
Rehabilitation Hospital on May 3, 1961, with a

172

CALIFORNIA MEDICINE

history of long-standing osteoarthritic involvement
of the knees and shoulders. He had received excel-
lent medical care for many years, including several
courses of intra-articular steroid therapy. However,
he had reached a period of diminishing return and.
when no longer able to take care of his needs at
home, applied for admission to the rehabilitation
hospital.

The patient, who was of pleasant disposition, was
able with great effort and obvious pain to take a
few steps with a cane. Otherwise he kept to a wheel
chair. Both knees were swollen and tender, with
the range of motion, both active and passive, very
limited and painful. Motion of the left shoulder
also was painful and restricted. A review of recent
x-ray films showed advanced hypertrophic, degen-
erative changes of both knee joints.

A program of intensive physical therapy, com-
bined with intra-articular injection of large doses of
steroids, was begun. The response was dramatic.
In two weeks the patient could walk without aid.
tenderness almost completely abated and there was
pronounced increase in range of motion of the knee
joints. On May 25, 1962, the patient was discharged
and thereafter was an outpatient at the Mount Sinai
Hospital Clinic. He received therapy twice weekly
and occasionally required an intra-articular injec-
tion for transitory swelling and pain. He could drive
an automobile and was fully ambulatory and in-
dependent in self care.

CONCLUSION

The dejected, and often rejected, resigned, dis-
abled, so-called “custodial geriatric patient” who
finds himself in a static and sedentary situation has
little need for preserving his ego strength. He tends
to withdraw and to avoid social contacts even with
equally involved patients in his immediate environ-
ment. That this is not. in most instances, an irre-

versible process was demonstrated in our study. The
challenge posed by this ever-expanding problem is
a double-edged one: On one side is the challenge to
the patient upon whom the dynamic forces converge
to attempt to overcome the inertia, the depression,
the loss of dignity and individual status; and on
the other side is the challenge to the community
and the rehabilitation staff, from physician to handy-
man, to provide the physical facilities and the
medical acumen and knowledge needed to restore
function, confidence and self-respect to the disabled,
geriatric patient. Ideally the goal is the prevention of
the loss of function, the preservation of human dig-
nity and a sense of identity. Less than ideally, but at
present the most practical approach, is the restora-
tion or maintenance of every disabled, elderly person
at the optimum level of physical performance, emo-
tional equilibrium and social relationship compatible
with his reservoir of potential strength in these areas.
As demonstrated in this study, in a significant num-
ber of cases the early and vigorous treatment of
physical disability in the elderly may make the
difference between developing a long-term, custodial
patient who is a drain on the community and of
little use to himself, and a restored, functioning
person who may return to his home and, in some
instances, to a contributing status in the community.

10921 Wilshire Boulevard, Los Angeles 24.

REFERENCES

1. Action for the Aged and Aging; A Report of the
Committee on Labor and Public Welfare of the United
States Senate, p. 56 (March 1961).

2. Aging Americans, Their Views and Living Conditions;
A Report by the Subcommittee on Problems of the Aged
and Aging of the Committee on Labor and Public Welfare,
United States Senate, p. 23 (Dec. 1960).

3. Aging in the States, National Advisory Committee for
the 1961 White House Conference on Aging, p. 127 (Jan.
1961).

4. United States National Health Survey, Series C, Vol. 6,
(July 1957-1959).

VOL. 97. NO. 3 •

SEPTEMBER 1962

173

Primary Adenocarcinoma of the Appendix

A Report of Two Cases

PAUL MICHAEL, M.D.

CLYN SMITH, JR.. M.D.

CARL DUBUY, M.D., and

JOHN ANDERSON, M.D., Monterey

Primary carcinoma of the appendix is a rare entity
which seldom is diagnosed clinically before opera-
tion. The simplest classification is that proposed by
Uihlein and McDonald in 1943:

1. Carcinoid tumors

2. Adenocarcinoma

(a) Mucinous adenocarcinoma associated with
mucocele

(b) Colonic adenocarcinoma

The appendix is the site of approximately 67 per
cent of all carcinoid tumors. According to Uihlein
and McDonald, 88 per cent of all carcinomas of the
appendix were of the carcinoid type; 8 per cent were
papillary cystadenocarcinomas (or mucocele), and
3.5 per cent were adenocarcinoma of the true colonic
type. Collins, who studied 50,000 appendices re-
moved surgically or examined postmortem, reported
that only 41 primary adenocarcinomas of the ap-
pendix were found, an incidence of 0.082 per cent
or one in every 1.200 appendices.

Sieracki and Tesluk in 1956 reported eight cases
of appendiceal carcinomas observed at the Henry
Ford Hospital and Pontiac General Hospital and
discussed reports of 42 cases they had collected from
the previous literature.

Excellent reviews were made by Braasch and Van-
sant in 1959 and by Sheridan and Pass in 1960.
Both emphasized the rarity of the tumor and the
need for proper therapy. For adenocarcinoma of the
mucinous type associated with mucocele, without
rupture, simple appendectomy should result in cure.
In adenocarcinoma of the colonic type, however,
hemicolectomy is indicated, since this tumor spreads
in a manner similar to that seen in colonic carci-
nomas and frequently involves lymph nodes.

Mucinous adenocarcinoma is frequently referred
to as malignant mucocele. It is more common than
colonic adenocarcinoma, is usually local, is fre-
quently encountered as the result of rupture. It

Submitted December 21, 1961.

spreads not by metastasis but by direct implantation
in the peritoneum, causing complications such as
intestinal obstruction and sepsis. In most instances
tumors of this order are discovered during explora-
tory laparotomy or operation done on suspicion of
acute appendicitis. The prognosis is good provided
spread or seeding of the peritoneum has not oc-
curred. Even if spread has begun, fairly long con-
tinued life can be expected.

Colonic adenocarcinoma, the rarest type of car-
cinoma of the appendix, simulates other colonic
tumors, especially those of the cecum. This tumor
histologically is fairly well differentiated but invades
the muscularis. It occurs principally in persons of
the older age groups and is rarely diagnosed pre-
operatively. Frequently it comes to the attention of
the patient because of pain simulating that of sub-
acute or acute appendicitis.

REPORTS OF CASES

Case 1. A 63-year-old woman entered the Mon-
terey Hospital because of abdominal pain in the
right lower quadrant of ten days’ duration. Except
for bouts of paroxysmal auricular tachycardia and
a mild degree of arteriosclerotic heart disease, the
patient had been in good health. The pain in the
right lower quadrant of the abdomen was persistent
and after five days was complicated by nausea and
vomiting. A day later the patient had two to three
black bowel movements. Then for the next two days
the feces were brown and the patient felt consid-
erably improved. The abdominal pain then returned
and increased in intensity.

When asked about bowel movements the patient
said she had become somewhat constipated during
the preceding month. Her body weight had de-
creased seven pounds in six months. At no time did
she have bright red blood in the stools.

Some five years previously the patient had a
vaginal hysterectomy and at that time had had some
symptoms referable to the urinary tract. The pathol-
ogist reported adenomyosis, endometrial hyperplasia,
endometrial polyp and carcinoma in situ of the
uterine cervix.

ETpon physical examination a very firm tender
mass, approximately 6x6 cm., was palpated in the
right lower quadrant of the abdomen.

174

CALIFORNIA MEDICINE

Hemoglobin content was 12 gm. per 100 cc. of
blood and leukocytes numbered 10,350 per cu. mm.
— 73 per cent segmented forms. 22 per cent lympho-
cytes and 5 per cent mononuclear cells. Results of
urinalysis were within normal limits.

X-ray examination with barium administered by
enema showed that the cecum was high and fixed
in position. The cecum and terminal ileum appeared
normal. The appendix did not fill. There was a
shadow in the pericecal region below the cecum,
considered to be an appendiceal abscess.

The clinical impression before operation was that
the three most likely diagnoses were (1) appendiceal
abscess; (2) perforating diverticulum of the cecum;
(3) perforating carcinoma of the cecum.

At operation a hard, oval mass about 6 cm. in
diameter was found attached to the anterior abdom-
inal wall in the right lower quadrant. Freed from
the abdominal wall and delivered into the wound,
it was observed to be a perforated appendix sur-
rounded by adherent omentum. The omentum was
left attached to the mass and a portion of it was
removed along with the appendix.

The pathologist’s report was as follows: “The
specimen consisted of an appendix showing a per-
foration in the middle third. Microscopically, an
invasive tumor infiltrating the muscularis was noted.
The cells were arranged in an adenomatous pattern
of a rather bizarre nature and there was a decided
inflammatory reaction associated with the neo-
plasm.”

The Tumor Board of the hospital advised right
hemicolectomy, which was done eight days after the
removal of the appendix. At the same time a strip
of peritoneum to which the appendix had originally
been adherent was removed.

The pathologist reported : “The tissue showed an
inflammatory reaction associated with some foreign
body response. Many histiocytes were present. Sec-
tions of the peritoneum revealed no evidence of any
residual tumor and numerous sections of lymph
nodes and cecum revealed no tumor present. The
cecum was free of any tumor.”

Comment

This was a low grade well differentiated colonic
adenocarcinoma originating in the appendix with
perforation. The fact that the surrounding omental
fat and the strip of peritoneal tissue were free of
tumor indicates a favorable prognosis.

Case 2. A 69-year-old woman, first seen in the
General Medical Clinic at Fort Ord, California, in
October of 1959, had been complaining of abdom-
inal pain for approximately a week. The pain at
first had been in the upper abdomen and later was
confined to the right lower quadrant, where it was
thought that a mass could be felt. Pelvic examina-
tion was carried out with the patient under general
anesthesia and a pear-shaped mass 7x2 cm., which
could not be definitely separated from the cecum,
was palpated.

Fluoroscopic studies with barium showed a ques-
tionable filling defect of the cecum. Films taken
after fluoroscopy showed that the barium had
passed through the ileocecal valve and the irregular
defect of the cecum still was present but whether
it was caused by an intrinsic or an extrinsic lesion
of the colon could not be determined.

Hemoglobin content of the blood was 13.2 gm.
per 100 cc. Leukocytes numbered 10,300 per cu.
mm. with 68 per cent neutrophils. The urine con-
tained many white blood cells and occasional hya-
line casts.

At operation a tumor involving the proximal half
of the appendix, adherent to the right fallopian tube
but not involving the cecum, was found. Adenocar-
cinoma was diagnosed by frozen section examina-
tion. Right hemicolectomy and resection of the right
tube and ovary were carried out. The pathologist
reported primary adenocarcinoma of the appendix
with no involvement of the cecum or fallopian tube.
One regional lymph node showed metastatic disease.

At the time of operation the gallbladder was pal-
pated and found to contain a single calculus. As it
was believed that some of the symptoms were asso-
ciated with this condition, a second operation was
carried out approximately four months after the
hemicolectomy. Widespread metastasis from the
appendiceal carcinoma was noted. Nodules of me-
tastatic tumor were observed in the wound on
opening the peritoneum and were also found in the
omentum and transverse mesocolon. Involvement
extended upward along the right colonic gutter in
the retroperitoneal tissues. The liver was free of
metastasis.

The immediate postoperative course was unevent-
ful and the patient was discharged home on the
fourteenth day. Her condition deteriorated over the
ensuing five or six months and on August 29 she
was admitted for terminal care because of abdom-
inal pain, nausea, vomiting and a loss of 16 pounds
in body weight. She died September 6, approx-
imately ten months after the original operation.
Necropsy was not done.

DISCUSSION

It is interesting that in both cases the patients
were women in the seventh decade of life. Both had
mild leukocytosis. In neither case was the diagnosis
established before operation, which corresponds
with the experience in most of the other reported
cases. The absence of metastatic lesions in the first
patient indicated a favorable prognosis; the pres-
ence of lymph node invasion in the second indicated
the probability of dissemination.

In both patients right hemicolectomy was done,
the best procedure for invasive carcinoma extending
beyond the mucosa. Adenocarcinoma in situ or
carcinoma confined to the mucosa or tip of an ade-
nomatous polyp may be treated safely by simple
appendectomy. Carcinoids or mucinous adenocar-
cinomas associated with mucocele without invasion

VOL. 97. NO. 3

SEPTEMBER 1962

175

or spread to adjacent nodes may also be safely
treated by appendectomy alone.

Monterey Hospital, Ltd., 576 Hartnell Street, Monterey (Michael).

Addendum: After this report was written, the author ob-
served another case of primary carcinoma of the appendix.

The patient was a 73-year-old man. He was operated on
for regional enteritis and the appendix was removed in-
cidentally. It was a rather short appendix with a diameter
of 2.5 cm. It was pale in color, solid in consistency and had
no visible lumen. Microscopically, mucinous adenocarcinoma
confined to the appendix was observed.

The Spreading of Warts by
Metal Expansion Watch Bands

A Report of Three Cases

CLETE DORSEY, M.D., Pasadena

The virus of warts is an inoculable organism.
Constant pressure as on weight bearing areas of
the feet, recurring nicks in the skin such as are
produced by shaving and acute and chronic trauma
of other kinds appear to be in some persons the
means of inducing and continuing an infestation
with warts. In the cases here reported warts devel-
oped and spread where a metal expansion watch
hand repeatedly nicked the skin at the wrist.

Case 1. A 45-year-old man had warts involv-
ing the left wrist and left hand and none elsewhere
on the body (Figures 1 and 2). The patient had a
nervous habit of pushing his watch band up and
down over the wrist. Often when he did this he was
aware of a mild stinging pain. In the skin area tra-
versed by the watch band in this up and down and
sideways movement there was a solid plaque of wart
tissue extending across the extensor surface of the
wrist. Trailing distally from this area were numer-
ous discrete warts on the sides of the hand and
thumb. It was obviously impractical to attempt re-
moval of the large area of wart on the dorsum of the
wrist. It was decided that the only therapeutic meas-
ure would be to advise the patient to discontinue the
wearing of the watch. Within two months all the
warts had disappeared.

Case 2. A 35-year-old man had warts on the
left wrist where the skin was nicked frequently
when he slid a metal expansion watch band up and
down. He said that when he wore the watch on the
right wrist, warts developed there also. When he
discontinued wearing the watch, all of the warts
on both wrists disappeared spontaneously.

Case 3. A 50-year-old man had warts scattered
over a large area on the extensor surface of the
arm from the wrist almost to the elbow. He was in
the habit of pushing his watch high up on his arm
when he worked. All warts disappeared spontane-
ously when the wearing of the metal expansion
watch band was discontinued.

Submitted February 26, 1962.

Figure 1. — Watch in position above wrist bones. Note
large wart plaque below watch, the linear plaque below
it and the discrete warts strung out distally. (All wart
tissue has been outlined with ink.)

Figure 2. — Watch in position below wrist bones. The
watch now covers the larger plaque. Note watch stem
resting on smaller, linear plaque. Discrete warts trail
away on sides of hand, the areas that are traumatized in
removing watch.

COMMENT

In these three cases, appreciation of the role of
the expansion metal watch-band in producing minor
trauma to the hairy part of the forearm was essen-
tial to the desired therapeutic result. It is probable
that if the warts had been destroyed in the ordinary
way, they would have returned again and again as
long as the watch bands were worn.

65 North Madison Avenue, Pasadena.

176

CALIFORNIA MEDICINE

Use of the Artificial Kidney in Snakebite

DONALD B. FRAZIER, M.D., and

FRANK H. CARTER, M.D., San Diego

At 1 :40 p.m. on October 19, 1959, a 33-year-old
Mexican laborer was bitten on the calf of the right
leg by a rattlesnake that was later identified as
Crotalus rubor rubor, or red diamond rattlesnake.3
Fifteen minutes later at a nearby hospital the pa-
tient was noted to be frothing at the mouth, was
tense and irritable and had generalized muscle fas-
ciculation. Oral temperature was 101° F. A single
fang mark was present on the right calf. Immediate
treatment consisted of 1,500 units of tetanus anti-
toxin, 75 milligrams of hydrocortisone sodium suc-
cinate (Solu-Cortef®) , cold compresses to the right
calf and 1 vial of Crotalus antivenin, half locally
around the bite and half intramuscularly. No in-
cision of the wound was made. The hemoglobin was
15.1 grams per 100 cc. and leukocytes numbered
27,000 per cu. mm. The following morning the oral
temperature was 104° F., the pulse rate 170 and
blood pressure 120/80 millimeters of mercury. Ex-
tensor rigidity suggesting ospisthotonos was present.
There were no conjunctival hemorrhages. The pupils
were pinpoint and the optical fundi were not visu-
alized. No abnormalities of lymph nodes, heart,
lungs or abdomen were noted. The deep tendon
reflexes were decreased. Plantar reflexes were within
normal limits. There was no localized tenderness,
redness or swelling about the site of the bite. In
spite of heavy sedation, soft restraints were required
for the safety of the patient.

Penicillin was administered and cooling meas-
ures carried out and by noon the temperature was
99° F. Hematemesis, hematuria and oliguria had
developed, however. A total of 5 vials of antivenin,
1.500 units of tetanus antitoxin and 1,200,009 units
of penicillin were given during the first 24 hours.
At no time was hypotension observed. In the eight
hours from 7 a.m. to 3 p.m. on October 20, 1959,
the patient’s fluid intake was 4.000 milliliters and
urinary output 290 milliliters. He was transferred
to the San Diego County General Hospital for fur-
ther observation and treatment.

On admission palpable right inguinal lymph
nodes were present and erythema extended from the
site of the bite in a linear fashion up the right calf,
hut no significant necrosis or swelling at the area
of inoculation was present. An electrocardiogram
was within normal limits. The urine was brown and
strongly positive for albumin and hemolyzed red
blood cells. Bleeding and coagulation times were
1 and 3 minutes. Prothrombin time was 96 per cent
of normal. The fibrinogen level was 0.5 gram per
100 cc. No significant change occurred in hemo-
globin values during the the first 96 hours. Hyper-
kalemia did not become a problem.

Presented before the Section on Urology at the 91st Annual Session
of the California Medical Association, San Francisco, April 15 to 18,
1962.

From the Department of Urology, San Diego County General Hos-
pital, San Diego.

• SEPTEMBER 1962

The patient remained oliguric; urine output for
each of the succeeding four days was 500 ml., 225
ml., 125 ml. and 80 ml. When symptoms of uremic
deterioration developed on the morning of the sixth
day, dialysis was carried out for five hours with a
disposable twin-coil artificial kidney. Transient
systolic hypertension — 160 millimeters of mercury
— developed at the end of the procedure. The blood
urea nitrogen was reduced from 138 mg. to 54 mg.
per 100 cc. Oliguria continued and on the tenth
hospital day dialysis for five hours was again car-
ried out. As before, transient systolic hypertension
developed, this time to 180 mm. of mercury. The
blood urea nitrogen, 134 mg. per 100 cc. before
dialysis, was 54 mg. after the procedure.

Progressive diuresis occurred and by the 17th
hospital day the urine output was 6,000 milliliters
per 24 hours. In spite of this, the blood urea nitro-
gen rose to 166 mg. per 100 cc. Then, with diuresis
continuing, the chemical contents of the blood re-
turned to normal limits in the next ten days.

On the 18th hospital day the blood pressure rose
to 220/100 mm. of mercury. He had right-sided
Jacksonian seizures and pneumothorax developed
on the left side. The hypertension responded to in-
travenous magnesium sulfate and sodium amytal.
Aspiration and suction drainage reduced the pneu-
mothorax and recovery was uneventful. The patient
was discharged on the 35th hospital day, feeling
well. The blood pressure and results of urinalysis
were within normal limits.

DISCUSSION

There are an estimated 1,500 cases of venomous
snake bite in the United States each year, approxi-
mately 70 per cent of them by rattlesnakes. Death
occurs in from 1.5 to 3 per cent of cases. Early
death from intravenous inoculation of Crotalus
venom is usually due to hemolytic shock or hemor-
rhage, or to central nervous system intoxication.
Later, renal failure may become a significant factor.

What are the components of Crotalus venom re-
sponsible for the production of renal failure? The
important hemolytic principle in Crotalus venom
is the enzyme lecithinase. This substance converts
the lecithin of the red blood cells or plasma to the
hemolytic agent lysolecithin, which acts by injuring
the red blood cell membrane, causing hemolysis.
This or a similar substance may also act directly
on the vascular endothelium to permit diapedesis
of red blood cells into tissue spaces.

Proteases convert prothrombin to thrombin, pro-
ducing intravascular fibrin clotting and afibrino-
genemia. The end result is local tissue necrosis and
remote visceral hemorrhage and infarction.

Hyaluronidase, another component in the in-
oculum, acts as a local venom-spreading factor.
(Enzymes which increase muscle excitability and
neurotoxins found in Crotalus venom will not be
discussed here.) The wide range of clinical mani-
festations of rattlesnake bite is probably owing to

177

VOL. 97, NO. 3

variation in the relative concentrations of the toxins
from one species to the next.

What is the renal lesion produced following rat-
tlesnake hite? Renal lesions produced experimen-
tally in animals by the administration of Crotalus
venom vary from slight granular degeneration of
the tubular epithelium to extensive exudative and
hemorrhagic lesions of the glomerular tufts. The
wide variation seen in animals suggests a correla-
tion with the human response.

Amorim and Mello1 described in detail the path-
ologic condition of the kidneys in three persons
bitten by Crotalus terrificus terrificus. The signifi-
cant findings were degeneration and desquamation
of tubular cells of the ascending limbs of Henle,
associated with intense interstitial inflammatory re-
sponse predominantly in the intermediate zone of
the kidney, characterized by neutrophilic leuko-
cytes, edema and histiocyte proliferation. Hemo-
globin casts were present in the distal convoluted
tubules and collecting tubules. Glomeruli were
spared. Proximal tubules showed cloudy swelling.
Capillary and precapillary hyperemia was promi-
nent. Grossly, multiple hemorrhagic foci in peri-
renal and renal tissues were noted. In short, the
lesions produced are those of hemoglobinuric ne-
phrosis. Whether these findings can be translated to
North American Crotalidae is unknown. The lesion
awaits description. Unfortunately renal biopsy was
not done in the case reported herein.

Because of the minimal local tissue reaction about
the site of the bite and the rapid onset of intense
systemic response we believe that the patient re-
ceived a direct intravenous inoculation of venom.
The presence of a single fang mark indicates that
the total volume of the inoculum was less than
would ordinarily be expected. Having survived the

initial impact, the patient’s problem became one of
severe although reversible renal failure.

If the renal lesion produced by North American
Crotalus venom is intermediate tubular necrosis, it
is most important that shock be prevented in order
to avoid the superimposition of ischemic tubular
necrosis upon the already damaged nephron. One
wonders whether the judicious use of Mannitol® (a
hexahydric alcohol) or other osmotic diuretic in
the early phase of treatment might he indicated to
support the circulation and maintain flow of urine.

Once renal failure is present, careful support and
extracorporeal or intraperitoneal dialysis are indi-
cated if this potentially reversible disease is to be
overcome.

SUMMARY

The clinical syndrome of acute renal failure de-
veloped following inoculation of venom by a rattle-
snake bite, apparently directly into a vein. Careful
supportive care alleviated the seriousness of the ini-
tial impact and use of the artificial kidney provided
the time for renal recovery.

6330 Alvarado Road, San Diego 20 (Carter).

REFERENCES

1. Amorim, M. F., and Mello, R. F. : Intermediate
nephron -nephrosis from snake poisoning in man, Am. J. of
Path., 30:479-499, May-June 1954.

2. Danzig, L. E., and Abels, G. H.: Hemodialysis of acute
renal failures following rattlesnake bite with recovery,
J.A.M.A., 175:136-137, January 14, 1961.

3. Klauber, L. M.: Rattlesnakes, Their Habits, Life His-
tories and Influence on Mankind, 2 vols., University of
California Press, Berkeley and Los Angeles, California,
1956.

4. Limbacher, H. P., and Lowe, C. H. : The treatment of
poisonous bites and stings, Arizona Med., 16:490-495, July
1959.

178

CALIFORNIA MEDICINE

^ E D I C I N

For information on preparation of manuscript, see advertising page 2

DWIGHT L. WILBUR, M.D Editor

ROBERT F. EDWARDS . . . Assistant to the Editor

Policy Committee — Editorial Board

OMER W. WHEELER, M.D Riverside

SAMUEL R. SHERMAN, M.D San Francisco

CARL E. ANDERSON, M.D Santa Rosa

JAMES C. DOYLE, M.D Beverly Hills

MATTHEW N. HOSMER, M.D San Francisco

IVAN C. HERON, M.D San Francisco

DWIGHT L. WILBUR, M.D San Francisco

EDITORIAL

•\ > ;-j .• __ .’v;.:-1.. '

Welcome Forty First

The unification of the California Medical Asso-
ciation and the California Osteopathic Association
is now a reality. What has been a program and a
series of steps for the past two years has now been
achieved and the two have become one.

There remains the formality of securing public
approval of the ballot proposition to set the future
duties of state boards but, regardless of the outcome
of that proposition at the polls, the two professions
have elfectively combined.

Formal steps were taken last month to issue a
charter to the Forty First Medical Society as a com-
ponent unit of the California Medical Association.
The society has reported its membership to the
C.M.A., has paid the dues of its members and has
thus enrolled them as members of the medical fra-
ternity of the state and the nation.

The Forty First Medical Society is statewide in
area. It was formed to provide a professional asso-
ciation for those coming anew into the C.M.A., an
organization similar to the 40 existing county soci-
eties. Its members are those who have now embraced
the M.D. degree and have applied for and been
elected to membership.

As a component of the California Medical Asso-
ciation, the Forty First has all the rights and privi-
leges of any other medical society in the state. For
example, it will have representation on the Council
of the Association and in the House of Delegates.
In each instance this representation will be based on
the society’s membership.

From the membership now reported, the Forty
First Medical Society will be entitled to two mem-
bers of the Council. The society has already selected
Doctors Joseph Cosentino and Forest J. Grunigen
for these posts and the Council has acted to appoint
them as members of the Council until the time of
the next annual session. At that time the members
of the House of Delegates from the Forty First will
elect their district councilors as all other districts do.

In the House of Delegates the Forty First Medical
Society will be entitled to 40 Delegates and a like
number of Alternates. These will be men of their
own choice, as is true with all other component
societies.

When the California College of Medicine con-
ferred the M.D. degree on a large class of applicants
in July, the C.M.A. was pleased to hold a series of
orientation meetings at which these points were
made plain. The structure of organized medicine
was outlined and a discussion of the commissions
and committees of the Association, their composi-
tion, selection of members and responsibilities was
outlined for these potential new members.

Today these new diplomates are members of the
C.M.A. and the A.M.A. and it is likely they have a
better grasp of the organization and operations of
the C.M.A. than do many of the older members.
They have the rights and privileges and duties that
go with membership in this democratically operated
organization.

It is fitting here to express a broad welcome to
the 1,900 new members coming into the C.M.A.
from the Forty First Medical Society. The same wel-
come applies to the society as a component unit of
the Association and to its officers and governing
members who conduct its affairs.

"Yes" on 22

In a short time members of the Association and
members of the general public will see evidence that
a YES vote is being requested on Proposition 22
on the November ballot: Newspapers, radio stations,
television stations, pamphlets, automobile bumper
strips, tent cards in physicians’ offices will ask and
ask again for an affirmative vote.

Proposition 22 was placed on the November gen-
eral election ballot by action of the State Legisla-

VOL. 97, NO. 3 • SEPTEMBER 1962

179

ture. Its terms tie in with a series of measures
passed by the Legislature and approved by the Gov-
ernor, all designed to create an orderly unification
of the medical and osteopathic professions in the
state.

While the unification program has progressed
smoothly to date, and while it wall remain in effect
regardless of the vote on 22, a YES vote on this
measure is a must if professional and public confu-
sion are to be eliminated.

This proposition provides that the jurisdiction
over those physicians who have now received the
M.D. degree and have elected to practice under this
discipline shall be transferred to the State Board of
Medical Examiners. It further provides that the
present Board of Osteopathic Examiners shall have
no future right to issue physician-and-surgeon li-
censes in California by reciprocity or by an initial
examination.

The osteopathic board would retain the right to
supervise those osteopathic licentiates who have
elected to retain the use of the D.O. degree, until
such time as the total number of those remaining is
decreased to 40. The hoard would then turn over its

final records to the Board of Medical Examiners
and go out of business.

This proposition has already been endorsed by
both gubernatorial candidates, by both professional
associations, by labor and by a large number of
civic organizations which have seen the wisdom
of maintaining in California only one high standard
of medical care. With the endorsements already is-
sued it would appear that there should be no ques-
tion about getting a YES vote.

On the other hand, there is opposition to this
proposal, centering principally in another state
where a national organization of osteopaths main-
tains headquarters. The opposition appears to cen-
ter its position on the claim of “monopoly.” The
claim is false; no one is denied access to the kind
of medical care he wishes to have and no one is
excluded from practice by Proposition 22.

Every physician should know that this ballot
proposition is good, is needed for completion of
the unification program and is designed to provide
the public with whatever is best in medical care.
Every physician should work for the passage of this
measure and should use his good offices in soliciting
votes for it.

Chloramphenicol

Since its introduction in 1948, chloramphenicol
has been used clinically with excellent success as a
wide-spectrum antibiotic. Annoying side effects such
as gastrointestinal intolerance and skin rashes have
been virtually absent. However, by 1950 it became
evident that it could cause serious and fatal ab-
normalities in the blood, and the Council on Phar-
macy and Chemistry of the American Medical
Association in 1954 advised that its use be restricted
to the treatment of typhoid fever and other serious
infectious diseases caused by chloramphenicol-sen-
sitive microorganisms that are resistant to other
antibiotics or to other forms of therapy. Neverthe-
less, the common use of the drug continued, and
fatality sometimes followed. Considering the amount
of drug prescribed (net sales in 1959 exceeded $70
million) the incidence of reported aplastic anemia
is low.

On the other hand, several recent studies using
sensitive hematologic means have indicated that
reversible erythroid depression occurs quite fre-
quently in patients receiving chloramphenicol.2,4 It
has been shown that before anemia develops there is
a fall in reticulocytes, a rise in serum iron with a
decrease in unsaturated iron-binding capacity, a de-

This editorial written for CALIFORNIA MEDICINE at the request
of the editor.

creased rate of radioiron disappearance from the
plasma and a delay in radioiron appearance in new
red cells. In the hone marrow, vacuoles appear in
the cytoplasm and nuclei of primitive erythroblasts
and the number of erythroblasts is decidedly re-
duced. In one series these changes were found in
16 out of 35 patients whose bone marrow was
examined carefully.4 In each patient blood and
marrow reverted to normal after the drug was dis-
continued. Transient decreases in numbers of white
cells and platelets occurred in most of these patients.
In another series when chloramphenicol dosage was
reduced but not discontinued, serum iron levels
returned to normal from previous elevation and
bone marrow abnormalities disappeared.5

Reversible depression of erythropoiesis following
the use of choramphenicol cannot be considered a
side reaction; it must be recognized as a pharma-
cological effect. It is more likely to occur in patients
with high levels of chloramphenicol in the blood1
and in patients with anemia or liver disease. At first
it was thought that the nitrobenzene moiety of the
chloramphenicol molecule was the cause of the
marrow depression. However, when the suspected
nitro group was replaced by a methyl sulfone group
the incidence of marrow depression actually in-
creased, demonstrating that the nitrobenzene part is
not primarily responsible.3

180

CALIFORNIA MEDICINE

There has been no consistent pattern in the de-
velopment of severe, irreversible aplastic anemia.
Red cells, white cells and megakaryocytes may all be
affected. Neither total dosage nor duration of ad-
ministration nor frequency of therapeutic periods
bears a constant relationship to it. Present evidence
suggests that factors in the host are important in
the development of these changes. Some patients
may be unusually sensitive to the pharmacologic
effect of the drug, or there may be variations in
their nutritional status or differences in absorption,
excretion or enzymatic inactivation of the drug. For
example, the use of chloramphenicol is particularly
hazardous in the newborn: Vasomotor collapse and
death may follow use of this antibiotic. In the new-
born there is excessive accumulation of chloram-
phenicol in the blood, since glucuronide conjuga-
tion, a normal elimination pathway for this drug,
is defective in the immature liver.

It has been suggested that patients who are re-
ceiving chloramphenicol should have frequent retic-
ulocyte counts or serum iron determinations to
detect evidence of bone marrow depression early.
This recommendation is based on the observation
that patients in whom reticulocytopenia, a rise in
serum iron and changes in bone marrow erythro-
blasts developed during chloramphenicol therapy,
had spontaneous remission of these changes when
the drug was discontinued. There is as yet no clear-
cut evidence that continued administration of

chloramphenicol usually leads to irreversible bone
marrow depression, or that early discontinuation is
followed invariably by remission. In cases in which
chloramphenicol is needed for proper treatment, it
actually may be inadvisable to stop giving the drug.

Since the relationship between aplastic anemia
and reversible changes in the blood and marrow is
as yet unknown and there is no reliable way of pre-
dicting the former by examination of the blood,
administration of chloramphenicol bears a certain
risk. For the time being, it would be advisable to
follow the recommendation of the Council on Phar-
macy and Chemistry and use the drug only if it is
specifically indicated and no other drug can do
the job.

Ralph 0. Wallerstein, M.D.

2000 Van Ness Avenue
San Francisco

REFERENCES

1. McCurdy, P. R. : Chloramphenicol blood levels and
bone marrow toxicity (abstract), Clin. Res., 10:27, 1962.

2. Rubin, D., Weisberger, A. S., Botti, R. E., and Sto-
raasli, J. P. : Changes in iron metabolism in early chloram-
phenicol toxicity, J. Clin. Invest., 37:1286, 1958.

3. Rubin, D., Weisberger, A. S., and Clark, D. R.: Early
detection of drug induced erythropoietic depression, J. Lab.
& Clin. Med., 56:453, 1960.

4. Saidi, P., Wallerstein, R. 0., and Aggeler, P. M. : Ef-
fect of chloramphenicol on erythropoiesis, J. Lab. & Clin.
Med., 57:247, 1961.

5. Sampson, W. I„ and Wallerstein, R. O., unpublished
observations.

VOL, 97. NO. 3

SEPTEMBER 1962

181

3 NEW

DEANS

MEDICAL SCHOOLS

CALIFORNIA

Three of California’s six medical
schools open their academic sessions
this fall under new deans. All will
have important parts to play in the
training of new physicians at a

DR. WELLS

time when medical practice, medical
research and medical education in
our state are drawing increasing
attention from physicians and others
in this country and abroad who have
special interest in the advancement
of medicine. Each has a reputation
of accomplishment that fits him
for the job at hand, and all of them
can begin this freshman year of their
deanship with the well-wishes of
their fellow members of the
medical profession.

Dr. Benjamin B. Wells comes to his post of dean
of California’s newest medical school with a back-
ground of training and experience that eminently
recommend him to the duties he undertakes.

The new dean, who assumed the top academic
post at California College of Medicine July 1, is a
doctor of philosophy as well as of medicine and has
held a number of teaching and administrative posts
in the 27 years since his graduation from Baylor
University College of Medicine. He began his career
in medical education as an instructor at Baylor.
Following service in the army in World War II
he was professor of medicine and dean of the Uni-
versity of Arkansas medical school, then professor
of medicine and chairman of the Department of
Medicine at Creighton University school of medi-
cine. In 1956 he went to Washington, D. C., as as-
sistant chief medical director for research and
education with the Veterans Administration depart-
ment of medicine and surgery.

Dr. Wells is a fellow of both the American Col-
lege of Physicians and the College of American
Pathologists. He has written two textbooks and
numerous journal articles in the field of clinical
pathology, and for a year in 1953-54 was a vice-
president and senior writer for W. B. Saunders
Company, Philadelphia.

Dr. Wells is married, has three children.

182

CALIFORNIA MEDICINE

DR. HINSHAW

Fifteen years after he was graduated from Loma
Linda University School of Medicine, Dr. David B.
Hinshaw became the dean of its faculty. He suc-
ceeded Dr. Walter E. Macpherson, who was made
the university’s vice-president for medical affairs.

At the time of his appointment to the deanship,
Dr. Hinshaw had been a member of the faculty for
some six years, most recently as professor of sur-
gery and chairman of the school’s department of
surgery.

After his graduation from Loma Linda, in 1947,
the new dean spent two years as an army medical
officer before beginning five years of residency and
specialty training leading to certification by the
American Board of Surgery in 1955. He is the
author of many scientific articles, particularly in
the areas of his special interest — problems of peptic
ulcer, gastric surgery and tissue homotransplanta-
tion. This research has been supported by substan-
tial grants from the U. S. Public Health Service.

Among the professional organizations of which
Dr. Hinshaw is a member are the American College
of Surgeons, the Pacific Coast Surgical Association,
the Society of University Surgeons, and the Los An-
geles County, California, and American Medical
Associations.

With his wife and their three children, he lives
in Arcadia.

DR. MELLINKOFF

Dr. Sherman M. Mellinkoff, who became dean
of the UCLA School of Medicine when Dr. Stafford
L. Warren was elevated to the newly created post
of vice-chancellor of health sciences at the medical
school, brought with him to his new position a rec-
ord of endorsement by both the faculty and the stu-
dents. In announcing the appointment. Chancellor
Franklin D. Murphy spoke of his “enthusiastic en-
dorsement by members of our medical faculty”;
and the classes of 1961 and 1962 voted him “the
professor who best exemplifies the teaching art.”
The new dean earned his M.D. degree at Stanford
University Medical School in 1944. Following two
years of service in the Army Medical Corps in
Korea, he did his first teaching as instructor in
medicine at Johns Hopkins. In 1953 he joined the
UCLA faculty as assistant professor of medicine.

A specialist in gastroenterology, he has more
than 60 scientific publications in this field.

Dr. Mellinkoff is a fellow of the American Col-
lege of Physicians and a member of the American
Association for the Advancement of Science, the
New York Academy of Sciences, American Federa-
tion for Clinical Research, American Board of
Internal Medicine, American Gastroenterological
Association and the American Institute of Nutrition.

He lives in Westwood with his wife June and
their three children.

VOL. 97, NO. 3 • SEPTEMBER 1962

183

^ r MEDICAL

ASSOCIATION

NOTICES & REPORTS

Council Meeting Minutes

Minutes of the 482nd Meeting of the Council, San

Francisco, Thunderbird Inn, July 7, 1962.

The meeting was called to order by Chairman
Anderson at the Thunderbird Inn. San Francisco
International Airport, on Saturday, July 7, 1962,
at 10:00 a.m.

Roll Call:

Present were President Wheeler. President-Elect
Sherman, Speaker Doyle, Vice-Speaker Heron,
Secretary Hosmer and Councilors MacLaggan. Wil-
son, Todd. Quinn. O’Neill. Bullock, O’Connor. Ham,
Rogers, Dalton, Murray, Davis, Miller, Watts,
Campbell, Morrison, Kaiser, Anderson and Dozier.
Doctor Edgar Wayburn sat with the Council as
Editor Pro Tern for Editor Wilbur.

A quorum present and acting.

Present by invitation were Messrs. Hunton,
Thomas, Clancy, Collins, Marvin, Whelan, Klutch,
Tobitt, Clark, Edwards and Bowman, Mrs. Griffith
and Doctor Batchelder of C.M.A. staff; Mr. Has-
sard, legal counsel; Mr. Salisbury, Public Health
League; county executives Scheuber of Alameda-
Contra Costa, Lingerfelt of Fresno, Geisert of Kern,
Baker of Los Angeles. Brayer of Riverside, Dochter-
man of Sacramento, Burris of San Diego, Neick of
San Francisco, Thompson and Monnich of San
Joaquin, Wood of San Mateo, Colvin of Santa Clara,
Brown of Sonoma, Bailey of Tulare, Rideout of
Butte-Glenn, and Grove of Monterey; Doctor Dan
Lieberman of the State Department of Mental
Hygiene; Doctor Harold M. Erickson of the State
Department of Public Health; Doctor Lester Mc-
Donald and Mrs. Eunice Evans of the State Depart-
ment of Social Welfare; Messrs. Heller, Nyron and
Wahlberg of California Physicians’ Service; Mr. J.
E. Bryan, consultant; Doctors Kandlbinder and
Hall of the Monterey County Medical Society;
Doctors Gerald W. Shaw, T. Eric Reynolds, Harold
Kay and others.

1. Minutes for Approval:

On motion duly made and seconded, minutes of
the 481st meeting of the Council, held May 19,
1962, were approved.

2. Membership:

(a) A report of membership as of July 5, 1962,
was presented and ordered filed.

(b) On motion duly made and seconded, 57 de-
linquent members, dues now paid, were voted re-
instatement.

(c) On motion duly made and seconded in each
instance, 11 applicants were elected to Associate
Membership. These were: Allyn E. Gilbert, Broor
A. Johnson, Alameda-Contra Costa; Robert J. Birn-
krant, Herman R. Casdorph, Donald W. Gaylor,
Doris L. Herman, Barbara M. Korsch, Boyd M.
Krout, Stanley R. M. Zerne, Los Angeles County;
Paul J. Sanazaro, San Francisco County; Robert
K. Harker, Ventura County.

fd) On motion duly made and seconded in
each instance, eight members were elected to Re-
tired Membership. These were: Frank S. Baxter,
Alameda-Contra Costa; Walter J. Sullivan, Los An-
geles County; Edward H. Brunemeier, Orange
County; Karl E. Kretzschmar, Riverside County;

OMER W. WHEELER, M.D President

SAMUEL R. SHERMAN, M.D President-Elect

JAMES C. DOYLE, M.D Speaker

IVAN C. HERON, M.D Vice-Speaker

CARL E. ANDERSON, M.D. . . Chairman of the Council
BURT L. DAVIS, M.D. . . Vice-Chairman of the Council

MATTHEW N. HOSMER, M.D Secretary

DWIGHT L. WILBUR, M.D Editor

HOWARD HASSARD Executive Director

JOHN HUNTON Executive Secretary

General Office, 693 Sutter Street, San Francisco 2 • PRospect 6-9400

ED CLANCY Director of Public Relations

Southern California Office:

2975 Wilshire Boulevard, Los Angeles 5 • DUnkirk 5-2341

184

CALIFORNIA MEDICINE

Paul R. Noetling, San Joaquin County; William
Cress, Santa Cruz County; Ervin M. Howarth, Ivan
N. Radeff. Ventura County.

(e) On motion duly made and seconded, reduc-
tions of dues were voted for 14 members because
of illness or postgraduate study.

3. Committee for Emergency Action:

President Wheeler reported that the Committee
for Emergency Action had discussed the appropri-
ate time for the conference of county society officers
and proposed that it he scheduled in conjunction
with the clinical session of the A.M.A. in Los An-
geles in late November. A motion to follow this
schedule was made and seconded but failed to pass.

On motion duly made and seconded, it was voted
to hold the Conference of County Society Officers in
January, 1963, in conjunction with the Council
meeting planned for January 12.

On motion duly made and seconded, it was voted
that the committee to arrange this conference
should consist of the senior officers of the Associa-
tion, together with one or two representatives each
from the Medical Executives Conference and the of-
ficers of the county societies. This committee would
prepare a program for the conference for approval
by the Council.

Doctor West reported on activities of an ad-
visory committee on medical education created in
response to a legislative act. On motion duly made
and seconded, it was voted that the Association
officers and staff give Doctor West every coopera-
tion and assistance.

4. Report of the President:

President Wheeler reported on plans made for
the granting of M.D. degrees by the California
College of Medicine on July 14 and 15, each con-
ferred group on these two days to attend a wel-
coming and orientation program following receipt of
the degree. He also reported that the Forty First
Medical Society, soon to be chartered, would be
eligible to two District Councilors and to propor-
tionate representation in the House of Delegates.

Doctor Wheeler further reported on questions
which have arisen relative to using the facilities of
county hospitals for patients under the Medical
Assistance to the Aged program. He suggested that
an ad hoc committee be appointed to review the
future role of county hospitals in our communities.
On motion duly made and seconded, it was voted
that such a committee be appointed by the Com-
mittee on Committees, to report back to the
Council.

Doctor Wheeler also reported that $25,000 has
been advanced from special state funds for a pilot
study on the provision of health care for migratory
workers.

5. State Department of Public Health:

Doctor Harold M. Erickson, deputy director of
the State Department of Public Health, reported
that 21 cases of paralytic poliomyelitis have been
reported this year, compared with 42 in the same
period of 1961 and 123 in 1960.

Doctor Erickson also reported that the depart-
ment will now accept Sabin oral vaccine as comply-
ing with legal requirements for polio immunization
of students and that a period of two weeks follow-
ing the opening of school will be allowed for the
required immunization.

6. State Department of Mental Hygiene:

Doctor Dan Lieberman outlined the campaign
of the department in recent years to control the
growth of new mental hospitals by (1) intensified
treatment in hospitals to provide a more rapid
turnover, (2) greater use of private facilities for
state patients, and (3) use of day hospitals. The
day hospitals are now established in San Diego
and San Francisco and a third planned for early
opening in Los Angeles. These hospitals are esti-
mated to be capable of absorbing a considerable
portion of the total patient load.

7. State Department of Social Welfare:

Mrs. Eunice Evans of the State Department of
Social Welfare reported that the Medical Assistance
to the Aged program appeared to be progressing
satisfactorily from the administrative and financial
points of view. There are now about 18,000 patients
in the program, of whom some 30 per cent have not
previously been recipients of public assistance.
About 8,000 of the present patients are in hospitals,
the balance in nursing homes and other facilities.
The percentage of those applying for M.A.A. and
not previously on public assistance is rising each
month.

Mrs. Evans also reported on an increase in the
Aid to the Totally Disabled program, on progress
in a coordinated home care program using “home
health aides” as non-medical personnel, and on
the increasing return of drug costs by pharma-
ceutical producers. She also reported that federal
funds are now available for the care of patients still
under the jurisdiction of mental health authorities.

Doctor Batchelder reported that the Joint Com-
mission for Health Care of the Aged is seeking to
establish a training course to determine the most
suitable methods for training “home health aides.”

8. Report of President-Elect:

President-Elect Sherman reported for the Com-
mittee on Committees a definition of “clinical in-
vestigator,” to read:

An investigator, conducting clinical investigations on the
treatment of human cancer, shall be defined as a duly

VOL. 97, NO. 3 • SEPTEMBER 1962

185

licensed physician and surgeon or other member of the heal-
ings arts who

(a) is actively connected in an official capacity with
or is a member of the staff of a bona fide medical
school, hospital approved by the Joint Commission on
Hospital Accreditation, research institution, or founda-
tion (similar to Rockefeller Foundation or Mayo Clinic)
which maintains adequate records for scientific analysis,
or,

(b) is approved, by an official state body, such as the
Department of Public Health, as qualified to conduct
clinical investigations on the treatment of human
cancer.

On motion duly made and seconded, this defini-
tion was approved.

Doctor Sherman also presented a statement of
the functions of the Liaison Committee to the Cali-
fornia Medical Assistants’ Association, to read:
Two fundamental areas are (1) Advisory and (2) Commun-
icative.

Advisory Functions

1. To give counsel or advice, when asked for it by a
member, an officer, or the Board of Trustees of C.M.A.A.

2. To volunteer assistance or advice in various areas
where essentially C.M.A. has had more experience than
C.M.A.A. As examples,

(a) A well-rounded diversified, and total concept on
program development. This phase would include medi-
cal business administration, legislative, public relations,
and para-medical topics, such as the MD-DO merger.

(b) Help develop an educational program for further
knowledge or a review of important subjects relating to
the overall fields of the medical secretary and/or medi-
cal assistant. This program may in the future be
adopted to needs developed in the proposed certifica-
tion program carried out on a national level.

(c) To act in an advisory capacity for the education
and promotion of encouraging C.M.A. members to have
their office secretaries and assistants join the local
county medical assistant association and thereby the
C.M.A.A. and A.A.M.A.

(d) To formulate and write specific articles, promot-
ing the public relations and overall patient care values
derived from employing C.M.A.A. members. These ar-
ticles would appear in both California Medicine and
the C.M.A.A. Bulletin thereby encouraging both doctors
and their employees to cooperate more fully in total
patient care.

3. To render financial direction and advice in certain
areas such as efficient executive office procedures, clerical
and secretarial help, publication of the bulletin, conventions,
Board of Trustee Meetings, etc., etc.

4. To offer help and advice regarding membership drives,
continuing interest, and participation of present members
and the formation of new chapters.

The area of attempting to interest C.M.A. members in
counties without medical assistants chapters could be an
especially important duty of this committee.

5. Let it be stated emphatically that all of these duties
specifically note that the committee has an advisory func-
tion and that its suggestions will never be mandatory for
acceptance by C.M.A.A.

Communicative Functions

1. To keep the C.M.A. Council and C.M.A.A. officers and
Board of Trustees informed of matters of mutual benefit and
interest.

On motion duly made and seconded, this state-
ment was approved.

9. California Physicians’ Service:

Councilor Morrison, as Board Chairman of
C.P.S., reported that despite increased sales resist-
ance to advanced dues resulting from increased
professional fee allowances, the membership was
holding at more than 1,000,000 and physician mem-
bership at more than 15,000.

Doctor Morrison presented a statement outlining
the problems of personnel and cost in a decreasing
program as fiscal administrator for public assist-
ance programs. Doctor T. Eric Reynolds, C.P.S.
president, elaborated on this problem and asked
that the Council adopt a position of supporting
C.P.S. in these programs. On motion duly made
and seconded, it was voted that the Council re-
affirm its position that the administration of gov-
ernmental medical assistance programs be vested
in California Physicians’ Service and that the Bu-
reau on Communications develop methods of mak-
ing this philosophy better known.

10. American Medical Association Meeting:

Doctor Doyle gave a review of the recent A.M.A.
meeting and reported on the disposition of resolu-
tions introduced by the California delegation.

11. Finance Committee:

It was reported that the Committee for Medical
Progress had requested approval of its budget and
contribution by the Association of its per capita
share. The Finance Committee approved this alloca-
tion of funds. On motion duly made and seconded,
the report of the Finance Committee was approved.

12. Bureau of Research and Planning:

Doctor Gerald W. Shaw, chairman of the Bureau
of Research and Planning, reported that a study
of communications, as represented by Newsletter,
had been completed. On motion duly made and
seconded, it was voted to refer this study to the
Bureau on Communications for review and for later
action by the Council.

Doctor Shaw also reported on a study on the
marketing of medical services, copies of which had
been forwarded to members of the Council. On
motion duly made and seconded, it was voted to
defer action on this report until the next Council
meeting in order to allow Councilors more time to
study the report.

186

CALIFORNIA MEDICINE

13. Commission on Medical Services:

Doctor Murray reported on the advisability of
completing work already started on the application
of the 1960 Relative Value Studies. On motion duly
made and seconded, approval was voted for this
continued study at a cost of about $600, funds for
which are included in the present budget. The
study, involving the cost of overhead, will be made
with the assistance of the Bureau of Research and
Planning.

14. Liaison Committee to Department of Social
Welfare:

Doctor Quinn reported that the Board of Social
Welfare has approved some changes in the drug
formulary. He also reported that consideration had
been given to the question of dispensing of drugs
by the attending physician and that the advisory
committee had voted that the Board should have
discretionary powers in this matter, especially in
areas where hardships for the patient might result
from a lack of pharmacy facilities. On motion duly
made and seconded, Doctor Quinn’s report was
approved.

15. Commission on Public Agencies:

Doctor MacLaggan reported that the ad hoc com-
mittee on mass polio immunization programs had
held several meetings and that six southern counties
would act in concert in a campaign in that area.

Doctor MacLaggan also reported that regional
hospital planning committees established by law in
the northern and southern areas are considering
several alternative proposals and that Doctor Ed-
ward Crane and Doctor Albert C. Daniels, medical
representatives, have asked suggestions. He pre-
sented a suggestion for a policy statement by the
Council, to read:

The Council of the California Medical Association, rec-
ognizing the need for sound hospital planning, recommends
that such planning can best be accomplished on a volun-
tary basis and that all approaches short of actual franchis-
ing should be given adequate trial prior to resorting to the
latter.

The Council further believes that regional hospital plan-
ning committees can legitimately be established by law
adopted by the Legislature but the charge given these com-
mittees by the Legislature should have sufficient flexibility
to allow them to operate on a voluntary basis and in the
best interest of the local community that they serve.

On motion duly made and seconded, this state-
ment was approved by the Council.

For the Committee on Other Professions, Doctor
Miller reported on hearings already held on the
question of the pharmaceutical vending machines
in hospitals. He reported that further hearings
would be held and asked authority for a staff
member to attend such hearings. On motion duly

VOL. 97, NO. 3 • SEPTEMBER 1962

made and seconded, authority was voted for a staff
representative to audit such hearings.

16. Commission on Community Health Services:

Doctor Harold Kay reported that the commission
had assigned to the appropriate committees all
resolutions referred to it following the 1962 Annual
Session. He also gave progress reports on the
activities of several committees under the Com-
mission.

17. Bureau on Communications:

Doctor Warren Bostick, chairman of the Bureau
on Communications, gave a progress report and
outlined the functions which the bureau proposes
to undertake in cooperation with other commissions
of the Association.

18. Commission on Medical Education:

Doctor Batchelder presented a request from one
scientific section for authority to align itself with
other organizations in promoting postgraduate and
other functions. On motion duly made and
seconded, it was voted to refer this request to the
ad hoc committee on the Scientific Board.

19. Medical Executives Conference:

Mr. Boyd Thompson, chairman of the Medical
Executives Conference, reported on a meeting held
the preceding day, at which two actions were voted
to be brought before the Council:

(a) It was recommended that the Committee on
Blood Banks of the Association, now scheduled to
be in its final year of existence, pay close attention
to and cooperate in the reorganization of the Cali-
fornia Blood Bank System.

(b) A statement relative to the financing of
mass oral poliomyelitis immunization campaigns,
approved by vote of the Medical Executive Confer-
ence, was presented for Council review and action,
as follows:

It is commonly accepted that mass polio immunization
programs must involve financial consideration both as to
income and expenditures.

The charge for such programs should be established at a
rate commensurate with the cost of the operation, and it
should be borne in mind that quality of this valuable public
service program should not suffer because of insufficient
income.

Expenditures of such a program are many and are ob-
viously in direct relationship to the size of the program.
These expenditures should be totally covered by the in-
come. In addition to the cost of the vaccine, all other costs
bearing directly upon the program should be taken into
consideration in the general listing of expenditures. Items
such as telephone, cost of personnel, transportation and
promotional materials are all acceptable expenditures which
should be reimbursable.

If any surplus funds result from these polio programs,
the surplus should be dispersed to public interest projects

187

health sciences library

UNIVERSITY OF MARYLAND
BALTIMORE

to be selected by each individual county society involved.
Examples of such projects are scholarship loans, community
public service projects, medical research, medical education,
etc. It is expected that accountable costs be reimbursable
from campaign proceeds but that no monies should be
diverted to the general budgets of medical societies for
costs other than those directly related to the polio cam-
paigns themselves.

A financial accounting of all income and expenditures,
as well as the disposition of any surplus monies, should
be a matter of public record.

On motion duly made and seconded, the report
of the Medical Executives Conference was approved.

20. Staff Report:

Mr. Hassard reported receipt of a request from
the Hospital Conference of Northern California for
support in seeking funds from the Department of
Health, Education and Welfare for hospital studies
proposed by the conference. It was pointed out that
a similar hospital conference had obtained such
funds without Association support. On motion duly
made and seconded, it was voted to decline this
request but to request that the county societies in

the affected areas be requested to lend their co-
operation in such studies.

As legal counsel, Mr. Hassard reported that two
suits filed against the Association and others in
connection with the unification program with
osteopaths had been decided in favor of the de-
fendants but that several weeks remain for these
cases to he appealed.

21. Future Meeting Dates:

The Council agreed that further meetings in 1962
should be held on August 25 in Los Angeles, Octo-
ber 6 in San Francisco, November 3 in Los An-
geles and December 15 in San Francisco. Meetings
are to start in executive session at 7:30 a.m.

Adjournment:

There being no further business to come before
it, the meeting was adjourned at 4:30 p.m. in
memory of Doctor Arthur L. Bloomfield, eminent
physician and educator.

Carl E. Anderson, M.D., Chairman
Matthew N. Hosmer, M.D., Secretary

CORRECTION

In the report of Transactions of the 1962 House of Delegates of the
California Medical Association, a part of the proposed Bylaw Amendment
No. 4, which appeared on page 115 of the August issue, was incorrectly
printed. As adopted by the House, the resolution read:

Resolved: That Chapter VII, Section 1, Subsection (a). Item 2, of the
Bylaws be amended to read as follows:

“2. Committee on Health Care of the Aged.”

188

CALIFORNIA MEDICINE

CALIFORNIA MEDICAL ASSOCIATION
1963 annual meeting
Ambassador Hotel, Los Angeles, March 24-27, 1963

announcing : last call for scientific exhibits,

MEDICAL MOTION PICTURES, SCIENTIFIC PAPERS

THIS IS YOUR MEETING .... PLAN TO PARTICIPATE

Do you have A SCIENTIFIC EXHIBIT? ... A MEDICAL MOTION PICTURE?

do non lu

fO you Dave A PAPER you’d like to present to your colleagues? . .
Write to the appropriate Section Secretary . . . Don’t delay . . . Do it today .
Programs are being planned now!

SECRETARIES OF THE SCIENTIFIC SECTIONS

ALLERGY

Walter R. MacLaren, M.D.

696 East Colorado Street, Pasadena 1

OBSTETRICS AND GYNECOLOGY . . Leon P. Fox, M.D.
303 North 15th Street, San Jose 12

ANESTHESIOLOGY James S. West, M.D.

Box 8914, Los Angeles 8

ORTHOPEDICS Edwin G. Bovill, Jr., M.D.

450 Sutter Street, San Francisco 8

DERMATOLOGY AND

SYPHILOLOGY Herbert L. Joseph, M.D.

1516 Napa Street, Vallejo

EAR, NOSE AND THROAT . . William F. Baxter, M.D.

762 Altos Oaks Drive, Los Altos

EYE . . . James F. Kleckner, M.D.

3731 Stocker Street, Los Angeles 8

GENERAL PRACTICE .... Herbert A. Holden, M.D.

383 West Joaquin Avenue, San Leandro

GENERAL SURGERY David B. Hinshaw, M.D.

Room 9440. 1200 North State Street,

Los Angeles 33

INDUSTRIAL MEDICINE AND

SURGERY Carl E. Nemethi, M.D.

5592 Santa Fe Avenue, Los Angeles 58

PATHOLOGY AND

BACTERIOLOGY Richard O. Myers, M.D.

Valley Presbyterian Hospital, 15107 Vanowen Street,

Van Nuys

PEDIATRICS Lawrence E. Reck, M.D.

2950 Sixth Avenue, San Diego 3

PHYSICAL MEDICINE Frances Baker, M.D.

1 Tilton Avenue, San Mateo

PREVENTIVE MEDICINE AND

PUBLIC HEALTH Herbert Bauer, M.D.

Yolo County Health Department, P.O. Box 532, Woodland

PSYCHIATRY AND NEUROLOGY . Henry S. Colony, M.D.
411 30th Street, Oakland 9

RADIOLOGY Walter Gaines, M.D.

120 St. Matthews Avenue, San Mateo

INTERNAL MEDICINE Harney M. Cordua, Jr., M.D.

2561 First Avenue, San Diego 3

UROLOGY

Henry Bodner, M.D.

4911 Van Nuys Boulevard, Van Nuys

VOL. 97, NO. 3

SEPTEMBER 1962

189

3n jHemoriam

Brown, Walter H., Palo Alto. Died August 6, 1962, in
Palo Alto, aged 86, of cerebral thrombosis. Graduate of
Jefferson Medical College, Philadelphia, 1906. Licensed in
California in 1928. Doctor Brown was a retired member of
the San Francisco Medical Society and the California Med-
ical Association, and an associate member of the American
Medical Association.

Butler, Fonzie William, Los Angeles. Died July 18,
1962, in Los Angeles, aged 63, of coronary thrombosis. Grad-
uate of Vanderbilt University School of Medicine, Nashville,
Tennessee, 1926. Licensed in California in 1935. Doctor But-
ler was a member of the Los Angeles County Medical Asso-
ciation. .

Canney, Philip C., San Francisco. Died July 12, 1962, in
San Rafael, aged 38. Graduate of Tufts College Medical
School, Boston, Massachusetts, 1947. Licensed in California
in 1957. Doctor Canney was a member of the San Francisco
Medical Society.

Ghrist, Orrie E., Glendale. Died in Glendale, August 5,
1962, of myocardial infarction, aged 67. Graduate of Stan-
ford University School of Medicine, Palo Alto-San Fran-
cisco, 1921. Licensed in California in 1921. Dr. Ghrist was a
member of the Los Angeles County Medical Association.

Gordon, George 0., Long Beach. Died July 18, 1962, in
Long Beach, aged 83. Graduate of Lincoln Medical College,
Eclectic, Lincoln, Nebraska, 1911. Licensed in California in
1922. Doctor Gordon was a retired member of the Los An-
geles Medical Association and the California Medical Asso-
ciation, and an associate member of the American Medical
Association. .

Gould, Arthur Abraham, Norwalk. Died July 25, 1962,
in Norwalk, aged 54, of arteriosclerotic heart disease. Grad-
uate of the University of Toronto Faculty of Medicine, Can-
ada, 1933. Licensed in California in 1934. Doctor Gould was
a member of the Los Angeles County Medical Association.

Hebert, Arthur Winfred, Lodi. Died July 30, 1962, in
Lodi, aged 75, of heart disease. Graduate of Jefferson Medi-
cal College, Philadelphia, 1916. Licensed in California in
1922. Doctor Hebert was a member of the San Joaquin
County Medical Society.

Jackson, John Ernest, Los Angeles. Died July 30, 1962,
in Los Angeles, aged 73, of hemorrhage from the cecum.
Graduate of the University of Nebraska College of Medi-
cine, Omaha, 1923. Licensed in California in 1926. Doctor
Jackson was a member of the Los Angeles County Medical
Association.

❖

Johnson, Donald W., Needles. Died July 22, 1962, in an
airplane crash in Torrance, aged 64. Graduate of Rush Med-
ical College, Chicago, 1923. Licensed in California in 1947.
Doctor Johnson was a member of the San Bernardino County
Medical Society.

Johnson, Weston P., Inglewood. Died July 23, 1962, in
Long Beach, aged 41. Graduate of the College of Medical
Evangelists, Loma Linda-Los Angeles, 1951. Licensed in
California in 1951. Doctor Johnson was a member of the
Los Angeles County Medical Association.

Leachman, Ream S., Vallejo. Died July 7, 1962, in Val-
lejo, aged 85. Graduate of Cooper Medical College, San
Francisco, 1912. Licensed in California in 1912. Doctor
Leachman was a member of the Solano County Medical So-
ciety, a life member of the California Medical Association,
and a member of the American Medical Association.

❖

Lewis, Harvey Alvin, Beverly Hills. Died July 21, 1962,
in Los Angeles, aged 50, of ventricular arrhythmia. Gradu-
ate of the University of Southern California School of Medi-
cine, Los Angeles, 1938. Licensed in California in 1938.
Doctor Lewis was a member of the Los Angeles County Med-
ical Association.

❖

Lorch, Alvin H., San Diego. Died July 23, 1962, in San
Diego, aged 56. Graduate of the State University of Iowa
College of Medicine, Iowa City, 1933. Licensed in California
in 1939. Doctor Lorch was a member of the San Diego
County Medical Society.

Mahlmann, Carl, Riverside. Died in 1962, aged 63.
Graduate of Hamburgische Universitat Medizinische Fakul-
tat, Hamburg, Germany, 1923. Licensed in California in
1945. Doctor Mahlmann was an associate member of the
Riverside County Medical Association.

Marsden, Samuel Arthur, Santa Ana. Died November
22, 1961, aged 76, of coronary thrombosis. Graduate of Col-
lege of Physicians and Surgeons, Los Angeles, 1917. Li-
censed in California in 1917. Doctor Marsden was a retired
member of the Orange County Medical Association and the
California Medical Association, and an associate member of
the American Medical Association.

Nisbet, Thomas W., Corona Del Mar. Died July 17, 1962,
in Newport Beach, aged 70. of pulmonary emphysema.
Graduate of Emory University School of Medicine, Atlanta,
Georgia, 1914. Licensed in California in 1924. Doctor Nisbet
was a member of the Los Angeles County Medical Associa-

Tobias, Siegfried Fritz, Grass Valley. Died June 29, 1962,
in Honolulu, aged 74, of heart disease. Graduate of the Uni-
versitat Heidelberg Medizinische Fakultat, Baden, Germany,
1910. Licensed in California in 1937. Doctor Tobias was a
member of the Placer-Nevada County Medical Society.

Westphal, Glenn Albert, Elsinore. Died July 10, 1962,
aged 64. Graduate of the College of Medical Evangelists
School of Medicine, Loma Linda-Los Angeles, 1932. Li-
censed in California in 1932. Doctor Westphal was a mem-
ber of the Riverside County Medical Association.

190

CALIFORNIA MEDICINE

&rtfcur H. ploomftelb

18884962

Dr. Arthur L. Bloomfield was a dominant
figure in the history of medicine in California.
For most of the 28 years he was Professor of
Medicine and Executive of the Department of
Medicine at the Stanford Medical School, he
was the leading intellectual figure in internal
medicine in the W est. A superb and beloved
teacher, an extraordinarily wise physician and
consultant, he had an amazing sense and feel
of the needs of students, of residents, of
patients, of physicians and of people. He
contributed greatly to the advancement of med-
icine, particularly knowledge of infectious dis-
eases, and was a pioneer in the clinical use of
pencillin and other antibiotics. California med-
icine is much richer for the life and contribu-
tions of this remarkable teacher, able scholar,
investigator and physician.

Dwight L. Wilbur

Dr. Arthur L. Bloomfield, outstanding Professor
of Medicine, Emeritus, of Stanford University
School of Medicine, died in his home, of coronary
thrombosis, at the age of 74 on July 5, 1962.

An only son of the Professor of Comparative
Philology at Johns Hopkins University, Dr. Bloom-
field was born in Baltimore on May 30, 1888. His
early education at Boys’ Latin School was an indica-
tion of what was to become his total immersion
in the academic life. He received the A.B. degree
from Johns Hopkins in 1907, the M.D. from its
medical school in 1911 just a few years after
William Osier departed and during Abraham Flex-
ner’s critical study of medical education. Eleven
years of a superior learning experience elapsed at
Johns Hopkins Hospital before Dr. Bloomfield
emerged as Associate Professor of Medicine, and
from that post he came to Stanford as Professor of
Medicine and Executive of the Department of Medi-
cine in 1926 upon the death of Professor A. W.
Hewlett. After his retirement in 1954, he served as
Consultant in Medicine at Fort Miley, the San
Francisco Veterans Administration Hospital.

His contributions to medical science were mani-
fold. An early interest in influenza, from the 1918
epidemic, directed him toward long-continued stud-
ies in infectious diseases. In this field he became a
consultant to the Secretary of War, was selected by
the government as a pioneer expert in this country
on penicillin, and was one of the first to use this
agent in the cure of patients with bacterial endo-

VOL. 97, NO. 3 • SEPTEMBER 1962

carditis, a previously fatal disease. He also studied
influenza and the common cold.

Another chief, continuing interest had to do with
peptic ulcer of the stomach and duodenum; he
wrote repeatedly on the cause of pain in this dis-
order, and with Dr. W. S. Polland published a
monograph on gastric secretion.

Important as were his scientific investigations, he
will be remembered by many primarily for his
extraordinary abilities as a physician and as a
teacher of medicine. One of the earliest and greatest
diagnosticians in the West, he had an almost un-
canny way of coming to the heart of a patient’s
problems even in the most complex situations, while
ignoring unimportant aspects which he recognized
as “peripheral.” The patient’s welfare and comfort
were of great concern to him; his goal was not
merely to make a diagnosis but to use his knowledge
in a practical way in order to help the patient, in
relieving symptoms and prolonging useful and
happy life in the best traditions of medicine. In
the most sincere recognition of his clinical success,
innumerable physicians selected Dr. Bloomfield as
consultant for themselves or for members of their
families.

His best teaching, and it was superb, came at the
bedside, where it was a memorable privilege and
real pleasure to observe Dr. Bloomfield intent at
his daily work. Small groups of students, interns
and resident physicians accompanied him on punc-
tual and regular rounds in the medical wards.
Weekly he demonstrated a few selected patients
before a group of his colleagues and practicing
physicians. Drawn by his profound knowledge of
medicine and by his free use of quotations to the
point from anyone from 0. Henry to Shakespeare,
this group became one of the largest of such exer-
cises in San Francisco or the Pacific Coast. In more
formal classroom exercises, few, if any, could equal
Dr. Bloomfield’s ability to prepare his material
with deep logic and present it with interest and
authority. He enjoyed open and friendly discussions
with his colleagues, and often agreed to disagree
with them for the sake of listening students.

A perpetual scholar himself, he took care to pro-
vide his students with glimpses of relevant historical
background as he discussed current clinical prob-
lems. Fortunately, some of this aspect of his work
remains in the form of A Bibliography of Internal
Medicine, in two volumes prepared largely after
Dr. Bloomfield’s retirement from active teaching.
“Here,” Professor William Bean wrote in the glow-
ing tribute of his book review, “is an example of
the scholarship, interest, and kind of charm and
excitement which can be found in medical history
when illuminated by the hand of a scholar, especi-

191

ally when that hand is guided and restrained by the
mature expertness of an outstanding clinician.”

Dr. Bloomfield’s interest in medical bibliography
was but a part of his love for books in general. He
had a fine library of first and rare editions, and was
a member of the California Book Club, of the
Organization of Bibliophiles and of the Roxburghe
Club; he was “Master of the Press” of the latter in
1961. He was director of the splendid historical
collection of Stanford’s Lane Medical Library, and
through his efforts gifts of more than $50,000 came
to the Library for the preservation and binding of
rare and valuable books and periodicals.

Although few had less interest than he did in
medical politics, Dr. Bloomfield’s stature was such
that he became president of the American Society
for Clinical Investigation, the California Academy
of Medicine, and the Pacific Interurban Club. He
was chosen as physician-in-chief pro tern at the Peter
Bent Brigham Hospital of Boston in 1951, was
selected in 1952 as one of the few to deliver George-
town Lhiiversity’s Kober Lecture, and received the
honorary degree of Doctor of Science from the
University of Southern California in 1953. He was
a Master of the American College of Physicians,
and also was a member of the Association of Amer-

ican Physicians, the Society for Experimental Bi-
ology and Medicine, the American Society for
Pharmacology and Experimental Therapeutics, the
American Society for Experimental Pathology, and
for a time was chairman of the Section of Medicine
of the American Medical Association. He was a
member of Phi Beta Kappa, Sigma Xi, and Alpha
Omega Alpha honorary societies, and was on the
editorial boards of the Archives of Internal Medi-
cine, the American Journal of Medicine, and the
Journal of Chronic Diseases.

He was honored at Stanford by an annual birth-
day party given by the medical interns and residents
for “The Professor,” by an “Arthur L. Bloomfield
Day” sponsored by the medical alumni upon his
retirement, by a festschrift number of their Stanford
Medical Bulletin dedicated to him a few months
later, and by the establishment of the Arthur L.
Bloomfield Professorship of Medicine.

Dr. Bloomfield is survived by his wife, Julia
Mayer Bloomfield, and three children: Julia Bloom-
field, Anne Bloomfield Saltonstall, and Arthur John
Bloomfield. Six grandchildren also survive.

Alvin J. Cox
Ernest R. Hilgard
David A. Rytand

192

CALIFORNIA MEDICINE

No. 11*

Acute Radiation Exposure

Radiation is unusual in that it is neither seen nor felt at the time of exposure. There-
fore, an individual can only voice a supposition that he has been exposed.

Most physicians lack the technical equipment and knowledge to measure radia-
tion. and therefore must request this help from other sources.

It is usually possible to reconstruct the circumstances as they were at the time
exposure is supposed to have occurred, and thereby determine if there was exposure
and, if so, in what quantity. To be effective, this investigation should be carried out
promptly, while all facts involved are fresh and undistorted by lapse of time.

Proper procedure answers (1) was there exposure, and (2) what was the amount
of exposure. Obviously if no significant exposure occurred, the matter can be dropped
from consideration.

Knowing the amount of exposure determines:

(a) Whether any active treatment is required other than observation and reassur-
rance (which in low dose cases is all that is needed) ;

(b) The prognosis as to probable course of the patient, and the ultimate residual
effects to be anticipated;

In most instances, with only the patient’s history, there is not sufficient basis for
a positive medical diagnosis of “radiation exposure.”

Due to increasing use of radiation sources, by industries and physicians, one can
anticipate an increasing number of persons believing they have suffered exposure.

It is detrimental to the individual to be treated on the basis of an inaccurate
diagnosis.

Proper medical procedure in the event of such a problem should be:

(a) Based on patient’s history, make initial diagnosis only of “Suspected Radia-
tion Exposure .”

(b) Request assistance from the local Health Department to determine if ex-
posure occurred, quantity of exposure, and what type of radiation exposure.

(c) When the facts are established, render, if possible, a positive diagnosis of “no
exposure” or “proven radiation exposure” and quantity.

(d) Guided by quantity of exposure, carry out indicated treatment.

(e) Institute preventive measures to avoid subsequent injuries.

Physicians need to recognize the necessity of promptly requesting available
sources of technical knowledge to assist them in this situation.

As in other fields, inaccurate diagnosis leads to increased litigation, which is detri-
mental to the patient as well as others.

The over-all problem of proper handling of radiation sources is of interest to
state government, particularly to the Division of Industrial Safety, which is respon-
sible for safety in the use of radiation sources, and to the State Department of Public
Health, which has a strong interest in this area. They should be notified of any inci-
dents involving known or suspected over-exposures to radiation that might result in
personal injury. In cases where neither the counsel of health physicists or specialized
medical assistance is immediately available, these departments of state government
may know where this kind of assistance may be obtained.

Committee of Occupational Health
California Medical Association

Comments and Questions Are Welcomed by the Committee

* This is the eleventh of a series of articles prepared by the Committee on Occupational Health.

VOL. 97. NO. 3 • SEPTEMBER 1962

PUBLIC HEALTH REPORT

MALCOLM H. MERRILL. M.D., M.P.H.
Director, State Department of Public Health

Today’s jet airliner has been pointed out so often
as a potential hazard in the spread of disease be-
tween countries that one tends to forget that ocean-
going vessels are quite capable of doing the same
thing in a slower manner.

Two recent occurrences of paratyphoid fever
aboard freighters coming here from Europe were
investigated by the quarantine stations and local
health departments of three California ports.

In the first case, a galley food handler was ap-
parently the carrier responsible for transmitting
paratyphoid fever to six other crew members, four
of whom had to be put in hospital. In the second
case, a freighter had to leave 11 crewmen along the
way, but by the time the ship arrived in California
the epidemic had burned itself out. None of the
passengers aboard either ship were involved and the
disease did not spread ashore at the ports visited.

Ships have played an important role in the pan-
demics of plague and cholera and in spite of all
required precautions can still serve to bring com-
municable diseases of all kinds to our shores.

111

There was some decrease in the death rate for
some selected cardiovascular diseases in California
from 1950 to 1960.

Data compiled by the Bureau of Vital Statistics
and Data Processing reveal that the death rate due
to diseases of the heart for the total population in
California has decreased about 10 per cent during
that period. This decrease of 10 per cent is also
evident among the female population.

The decrease is in all ages and particularly in the
age groups 45 to 54 and 55 to 64. For coronary
heart disease the age specific death rate also showed
a decreasing trend between 1950 and 1960 — about
15 per cent between the beginning and the end of
the decade. i i

A study of the transmissibility of rabies from in-
sectivorous bats to terrestrial animals is being car-
ried out at the Southwest Rabies Investigation
Station of the U. S. Public Health Service at Las
Cruces, New Mexico.

Of particular significance is the recent work of
the station in demonstrating the natural aerosol
transmission of rabies in bats to coyotes and foxes
in Texas caves.

The work demonstrates the probable route of
transmission for the human case of rabies which

occurred in a California mining engineer who died
of the disease in Los Angeles in June 1959. The
work likewise opens up new avenues of investigation
to determine routes of rabies virus excretion and
infection among freetail bats — that is, kidney to
lung, lung to lung, and mammary gland to alimen-
tary tract — and provides a rationale for the high
rate of infection which has been observed in Mexi-
can colonial freetail bats in the Southwestern United
States.

ill

California has experienced its first recorded cases
of shellfish intoxication from consumption of oys-
ters. Four Solano County residents became ill after
eating oysters on August 1. They experienced tin-
gling of the lips, numbness of the extremities, mus-
cle incoordination and difficulty in walking.

The oysters were purchased in a restaurant near
Tomales Bay which obtained them from a commer-
cial bed in Drakes Bay. Samples of the oysters
purchased showed 1,920 micrograms of toxin per
100 grams of meat, or 24 times the upper safe limit.
Shipments for the present were immediately pro-
hibited from the Drakes Bay bed and all recent
distributions recalled by the operators.

Shellfish poisoning results from ingestion by shell-
fish of the dinoflagellate, Gonyaulaux catanella, a
microscopic unicellular plankton organism responsi-
ble for the so-called “red tide.” At times when
millions per liter are present, the sea has a deep
rust red color and beautiful luminescence. Califor-
nia’s past intoxications have been with mussels and
clams, but oysters were involved in human poisoning
in British Columbia in 1957.

The first known outbreak on the Pacific Coast
was in 1790 when the Russian Baranoff expedition
lost some 100 men from what they called “mussell
poisoning” in Sitka, Alaska. In 1793, Captain Van-
couver’s exploring party experienced difficulty with
similar poisoning near the island which bears the
explorer’s name.

From 1927-1959, California had 373 cases with
30 deaths. Of these, 20 cases and five deaths were
from clams, the rest followed the eating of mussels.
All cases occurred between May 15 and October 26.
Each year the department issues a quarantine order
prohibiting the taking, sale or offering of mussels
from May 1 to October 31, and a warning not to
eat the dark portions of clams during that period.

194

CALIFORNIA MEDICINE

INFORMATION

Type of Practice of Physicians in Non-
Federal Practice in California for
Three Periods: Mid-1959 to January,
1962; and Other Comparative Data

A Report of the Bureau of Research and
Planning, California Medical Association

Detailed data to be published by tbe Bureau of
Research and Planning in tbe near future on one
phase of its study of the characteristics of physicians
provide the bases for a comparison of tbe numbers
of non-federal" physicians in California between
June, 1959, and January, 1962. Tbe change in tbe
patterns in California in that two and a half year
period is presented in Table 1.

The number of physicians in non-federal practice
increased by 2,666 between June, 1959, and Janu-
ary, 1962.

Although tbe proportion of physicians in private
practice to ether physicians remains the same, full-
time specialists increased about 31 per cent, and
general practitioners decreased by 13 per cent.

All other types of practice increased, with physi-
cians in teaching, administration, research, etc.,
showing the greatest gain of all groups — over 42
per cent.

Table 2 compares the proportion of physicians in
non-federal practice in California with eorrespond-

'Not regularly employed in any of the agencies of the Federal
Government.

The total number of non-federal* physicians in
California rose from 23,065 in mid-1959 to 26,271
in January, 1962, an 11.3 per cent increase. The pro-
portion of physicians in private active practice re-
mained almost constant during this period.

A significant rise, both in number and propor-
tionally, look place in the full-time specialty cate-
gory, offset by losses in the general practice-part-
lime specialty group. While specialists increased
by over 30 per cent, general practitioners, who
made up 31.7 per cent of all non-federal physicians
in 1959, were only 24.7 per cent of the total in early
1962.

ing data for the United States as of the beginning
of 1962. The most significant differences in the dis-
tribution are those which show California’s higher
proportion of full-time specialists and its corre-
spondingly lower proportion of general practitioners
than for the country as a whole. Noteworthy also
is tbe higher proportion in California of physicians
who are retired or otherwise not engaged in medical
practice.

California Medical Association, 693 Sutter Street, San Francisco 2.

TABLE 2. — Distribution of Non-Federal Physicians, by Type of
Practice for California and the United States, January, 7962§

(

California
Per Cent

Total
United
States
Per Cent

United
States
( Excluding
California >
Per Cent

Full-time specialty

47.7

42.2

41.6

General practice

24.7

29.9

30.5

Hospital services

15.4

17.9

18.2

All other

4.6

4.8

Retired and not in practice

7.6

5.2

4.9

Total

100.0

(26,271) (237,763) (211,492)

§ Sources : 1959 Data — Health Manpower Source Book, U. S. Dept,
of HEW. 1961 Data — Bureau of Research and Planning, Tabulations
of IBM cards from the AMA. 1962 Data —Distribution of Physicians
for January, 1962, Department of Circulation and Records, AMA.

TABLE 1. — Changes in Type of Practice of Non-Federal Physicians. June, 7959 to January, 7962, in California §

Type of Practice

General practice* 7,482 31.7 6,705 26.4 6,483 24.7 —13.4

Full-time specialty 9,587 40.6 11,859 46.6 12,519 47.7 +30.6

All hospital services* 3,885 16.5 3,994 15.7 4,058 15.4 + 4.5

Other* 856 3.6 946 3.7 1,216 4.6 +42.5

Retired and not in practice 1,795 7.6 1,936 7.6 1,995 7.6 +11.1

Total 23,605 100.0 25,440 100.0 26,271 100.0 +11.3

‘Includes General Praciice and Part-Time Specialty,
tlncludes Interns, Residents, and Full-Time Hospital Staff.

{Includes Medical School Faculty, Medical Administration, Research, and Non-Federal Public Health, Dentists, and Industrial and Insur-
ance Company Physicians.

§ Sources : 1959 data — Health Manpower Source Book, U. S. Dept, of HEW. 1961 Data — Bureau of Research and Planning, Tabulations
of IBM cards from the AMA. 1962 Data — Distribution of Physicians for January, 1962, Department of Circulation and Records, AMA.

Total Physicians by Type of Practice

June, 1959

April, 1961

January, 1962

Per Cent

Per Cent
Change
June, 1959-
January, 1962

VOL. 97. NO. 3

SEPTEMBER 1962

195

The Importance of
Auxiliary Membership

Why, if your wife is a member of the Junior
League, the Assistance League, the Hospital Guild
or other organizations, does she expect to give a
certain number of hours of her time each week or
month in “service” for that organization and the
community, but she may not necessarily think it
essential to give equal time to her county medical
auxiliary?

Our auxiliaries have a worthy goal, worthy proj-
ects. We want to help keep medicine unfettered. We
work to promote public health. Attendance at our
meetings should be just as important to your wife
as her “service” time is to other organizations.

From National Auxiliary to State Auxiliary to
County Auxiliary an effort is under way in pro-
gramming to give our members useful information
about the worthwhile committees functioning in the
auxiliary that could use their time and talents.

Although legislation will continue to be in first
place in activity, A.M.P.A.C. will be able to present
programs to arouse fresh interest in the need for
our participation in combatting any threat to our
freedom.

Quackery in all its forms will be exposed by pro-
grams. This is again big business. We have an
obligation to inform our communities on quackery

— in diet, nutrition, cosmetics, cancer, arthritis, etc.
Programs to make our members aware of the exist-
ence of quackery will allow them to alert their
friends and neighbors to the dangers.

Safety, especially in the home, will be brought to
the attention of our members by programs. So
many hidden dangers can be exposed, and in an
interesting manner. This program is presented in
conjunction with the National Safety Council.

The new International Health Committee will wish
to present programs to outline their projects which
will arouse enthusiasm in many communities. The
collection of items for use overseas in underprivi-
leged areas has always been supported by the doc-
tors’ wives, but never has the collection been better
organized.

The program committee in presenting the activi-
ties of all the projects of the auxiliary is able
through programs to interest all of the members in
the true value of auxiliary. How better can a mem-
ber use her time than to donate a part of it each
week or month to one of the many committees
earnestly endeavoring to give to America the best
health and medicine in the world.

Mrs. Lyle F. Murphy

Second. Vice-President and
Program Chairman
Woman’s Auxiliary to the
California Medical Association

196

CALIFORNIA MEDICINE

NEWS & NOTES

NATIONAL • STATE • COUNTY

LOS ANGELES

The fifteenth annual Midwinter Radiological Confer-
ence, sponsored by the Los Angeles Radiological Society,
will be held at the Biltmore Hotel, Los Angeles, on Febru-
ary 2 and 3.

Guest speakers will be Dr. Ingomar Wickbom, Goteberg,
Sweden; Dr. Robert E. Steiner, Hammersmith Hospital,
London; Dr. Walter T. Murphy, Roswell Park Memorial
Institute, Buffalo; and Dr. John A. Campbell, Indiana Uni-
versity Medical Center, Indianapolis.

* * *

Dr. Irving Gordon, professor and head of the depart-
ment of medical microbiology at the University of Southern
California School of Medicine, has been made a member of
the Training Grant Committee of the Institute of Allergy
and Infectious Diseases of the National Institutes of Health.
* * *

Dr. Mareo R. Rago of Beverly Hills has been appointed
to the State Board of Public Health by Governor Edmund
Brown. He succeeds Dr. Dave F. Dozier of Sacramento
who completed six years of service on the board.

Dr. Charles E. Smith, dean of the School of Public
Health at the University of California, Berkeley, who was
first appointed to the board in 1940, was reappointed.

* * *

Dr. Clinton H. Thienes has retired as director of the

Institute of Medical Research of the Huntington Memorial
Hospital, but will continue his association with the Insti-
tute as Consultant. Dr. Thienes is also Adjunct Professor
of Pharmacology at the University of Southern California
School of Medicine.

^ *f*

A research fellowship in clinical cardiovascular

physiology is available in the Department of Medicine at
the University of Southern California School of Medicine.
The appointment is to be for one to two years. Emphasis
is on physiological investigations in patients for study of
hemodynamic mechanisms of shock and other cardiovascu-
lar diseases. Applicants must be licensed or eligible for
medical licensure in California.

Further information may be obtained from Max H. Weil,
M.D., assistant professor of medicine, University of South-
ern California School of Medicine, 2025 Zonal Avenue, Los
Angeles 33.

* * *

The thirty-second annual midwinter clinical convention
of the Research Study Club of Los Angeles for ophthal-
mologists and otolaryngologists will be held at The Statler
Hilton Hotel, from January 21st through the 25th, 1963. at
the Statler Hilton Hotel in Los Angeles.

SAN FRANCISCO

The 1962 scientific assembly of the California Academy
of General Practice will be held in San Francisco, Octo-
ber 21 to 24. All sessions will be held at the Masonic Mem-
orial Temple on Nob Hill. Out of state lecturers will in-
clude Dr. C. Harden Branch, professor of psychiatry, Uni-

versity of Utah; Dr. James L. Dennis, professor of pedi-
atrics, University of Arkansas; Dr. William Dock, professor
of medicine, State University of New York; Dr. Perry S.
MacNeal, associate professor of clinical medicine, Univer-
sity of Pennsylvania; Dr. George Pack, neoplastic surgeon,
Memorial Hospital for Cancer, New York; and Dr. Walter
J. Reich, professor of gynecology. Cook County Graduate
School, Chicago.

GENERAL

The Fourth Regional Rural Health Conference spon-
sored by the American Medical Association Council on
Rural Health, will be held in Sacramento October 19 and
20, 1962. Representatives from Idaho, Nevada, Arizona,
Washington and Oregon will be guests of the California
Medical Association Committee on Rural Health.

The state committees will be augmented by A.M.A. re-
gional councilors Dr. Herbert E. Mason, of Beaverton, Ore-
gon, and Dr. Carroll B. Andrews, of Sonoma, California.

C.M.A. President Omer W. Wheeler will open the meet-
ing with greetings from the California association.

Dr. Dave F. Dozier, a former member of the State Board
of Public Health and a C.M.A. Councillor, will moderate a
panel on “Safeguarding the Health of Rural People.” The
panel will consist of:

Seasonal Worker Health Problems — Bruce Joseph,
M.D., consultant California Department of Public Health,
Berkeley.

Rural Hospital Problems — Mrs. Dagmar D. Fulton,
Pleasanton.

The Doctor’s Responsibility — Joseph E. Fischnaller,
M.D., Omak, Washington.

Family Responsibility — Mrs. Leopold J. Snyder, Fresno,
Regional Chairman for Rural Health, Woman’s Auxiliary
to the American Medical Association.

Animal Diseases Dangerous to Man — Dr. W. R. Pritch-
ard, dean of the University of California School of Vet-
erinary Medicine.

Poison Dangers — Dr. Virgil Haven Freed, Oregon State
College, Corvallis.

A banquet the evening of October 19 will be addressed
by Louis A. Rozzini, president of the California Farm Bu-
reau Federation.

The meeting on the second day will be concerned with
needs for personnel recruitment and planning for future
developments in rural medical care. The discussants
will be Alfred M. Popma, M.D., member of the Western
Interstate Commission for Higher Education, Boise, Idaho;
Robert M. Crede, M.D., assistant dean, University of Cali-
fornia Medical Center, San Francisco; Henry Gibbons, III,
M.D., delegate, American Medical Association, San Fran-
cisco; Carroll B. Andrews, M.D., member of the Council on
Rural Health, A.M.A., Sonoma, California; C. M. Love,
Ph.D., department of life science, Sacramento State College,
Sacramento; Herbert L. Hartley, M.D., editor, Northwest
Medicine, Seattle.

* * *

The appointment of 13 medical scientists to the Com-
mission on Drug Safety was announced recently by Com-
mission Chairman Lowell T. Coggeshall, M.D., vice-presi-
dent and professor of medicine at the University of Chicago.
The members of the Commission are :

Dr. Paul R. Cannon, pathologist, former chairman of the
department of pathology at the University of Chicago, and
professor of pathology at the university for 25 years. He is
editor of the American Medical Association’s Archives of
Pathology.

VOL. 97, NO. 3

SEPTEMBER 1962

197

Dr. Thomas Francis, Jr., professor of epidemiology and
chairman of the department of epidemiology at the Univer-
sity of Michigan Medical School since 1941.

Dr. Philip S. Hench, Nobel prize winning authority on
arthritis and rheumatism. He has been associated with the
Mayo Foundation and graduate school of the University of
Minnesota since 1921, as professor of medicine there since
1947.

Dr. Hugh H. Hussey, Jr., dean and professor of medicine
at the Georgetown University School of Medicine in Wash-
ington, D. C. He is a specialist in internal medicine.

Dr. Chester S. Keefer, former special assistant to the
Secretary of Health, Education, and Welfare and a director
of Boston University-Massachusetts Memorial Hospitals'
Medical Center since 1959. He has been professor of medi-
cine at Boston University since 1940.

Dr. Theodore G. Klumpp, former chief of the drug divi-
sion, Food and Drug Administration, and instructor in inter-
nal medicine at Yale. He is president and director of Win-
throp Laboratories of New York City.

Dr. John T. Litchfield, specialist in pharmacology and
drug safety evaluation, and director of the experimental
therapeutics research section of Lederle Laboratories, Pearl
River, N. Y.

Dr. Maurice R. Nance, an internist with special training
in pathology. He is medical director of Smith. Kline and
French Laboratories in Philadelphia.

Dr. Leonard A. Scheele, former career officer with the
U. S. Public Health Service and Surgeon General from
1948 to 1956. He is senior vice-president of Warner-Lambert
Pharmaceutical Company of Morris Plains, N. J.

Dr. Leon H. Schmit, pharmacologist, research professor
in biological chemistry at the University of Cincinnati Col-
lege of Medicine since 1950, and consultant to the National
Institutes of Health.

Dr. Austin Smith, former editor of the Journal of the
American Medical Association, editor-in-chief of all A.M.A.

scientific publications, and executive editor of the World
Medical Journal. He is president of the Pharmaceutical
Manufacturers Association.

Dr. Thomas B. Turner, microbiologist, dean of the medi-
cal faculty of Johns Hopkins School of Medicine since 1957,
an authority on spirochetal diseases and poliomyelitis.

Dr. Josef Warkany, pediatrician, noted for his research
in endocrinology and prenatal deformities. He is a fellow
of the Children’s Hospital Research Foundation in Cin-
cinnati.

* * *

More effective controls of medical quackery in California
will be sought in San Francisco on October 10 when repre-
sentatives of five groups in the health field meet for the
California Congress on Medical Quackery.

The one-day program, at the Del Webb Townehouse, is
sponsored by the California Medical Association in coopera-
tion with the Arthritis and Rheumatism Foundation, the
American Cancer Society, the Food and Drug Administra-
tion and the California State Department of Public Health.

Detailed information may be secured from Eugene G.
Miller, M.D., Coordinator, C.M.A. Commission on Cancer,
875 O'Farrell Street, San Francisco.

* * *

The Sixth International Congress of Gerontology,

with Denmark, Finland, Norway and Sweden as hosts, will
be held August 11 to 16, 1963, in Copenhagen, with one-day
sessions being held in Malme and Lund, Sweden.

Symposia and sessions for papers are being organized
within four divisions: Biological research; social sciences
and psychological research; medical and clinical research;
and social welfare research.

Scientists in this country who wish to present papers
may obtain the necessary information from Dr. Ralph Gold-
man, secretary, American Branch, Clinical Medicine Re-
search Committee, International Association of Gerontology,
University of California Medical Center, Los Angeles 24.

CALIFORNIA MEDICINE

198

THE PHYSICIAN'S

SELF-HYPNOSIS — A Conditioned- Response Technique

— Laurence Sparks. Grune & Stratton, Inc., 381 Park
Avenue South, New York 16, N. Y., 1962. 255 pages, $5.75.

Of the spate of books on hypnosis that appear in such
abundance currently, this one, “Self-Hypnosis,” by Lawrence
Sparks brings little to this field, which is new. This book
purports to demonstrate that a fair number of persons can
be trained to treat themselves for a variety of illnesses by
the technique described before by a number of authors of
so-called self-hypnosis.

The many theoretical and practical problems that this
technique posits appear to interest the author not at all.
There is an abundance of evidence to show that indigenous
within every neurotic person is an alien and hostile pro-
pensity reluctant from a primitive identification with re-
jecting parental figures which one might call a harsh
punitive super ego. This portion of the personality actively
works against the patient’s best interest. This is uncon-
scious and is demontrative of the biblical statement that
“thy right hand knoweth not and thy left hand doeth.” This
phenomenon has been abundantly demonstrated in psychia-
try. This reviewer has seen a number of unhappy results
resulting from patients who have treated themselves by
self-hypnotic techniques and it is unfortunate that the
author had seemingly so little interest in any detailed
controlled study of hypnosis. In this application he presents
no data of controlled results which are convincing that such
a technique is effective or safe and like most lay persons
who are interested in hypnosis, he has not, in the opinion
of the reviewer, the degree of training in the behavioral
sciences which would make such a scientific inquiry
possible.

Until such time as such data gathered and evaluated
by qualified psychiatrists are available to us, one is
prompted to conclude that the person who treats himself by
these methods for a neurotic illness is comparable to the
physician who treats himself and of whom it has been
said “he has a fool for a physician and an ass for a
patient.”

Charles W. Wahl, M.D.

* * *

SUICIDE AND MASS SU ICI DE — Joost A. M. Meerloo,
M.D., Ph.D. Grune & Stratton, Inc., 381 Park Avenue
South, New York 16, N. Y., 1962. 153 pages, $3.75.

Dr. Meerloo, in this book, “Suicide and Mass Suicide,”
has in the opinion of the reviewer, brought little that is
new to this important and much studied phenomenon.

He has, however, compressed in a book of small compass
a most complete description of the theories of etiology
of suicide of which I have ever seen described. The various
dynamic factors are also illustrated by examples of his
own and other case material, and he has avoided the pitfall
that seems to beset most writers on this subject; namely,
that of oversimplification and dogmatism. In addition to
discussing the numerous and subtle motives for personal

suicide, he describes at length the relationship between the
individual action and the sociological phenomena of mass
hysteria and group frenzy. Lastly, he considers I he efforts
individually and collectively which are being made to detect
and treat the potentially suicidal person.

This book is recommended for purchase. It contains much
in its scant 144 pages. Charles W. Wahl, M.D.

* * *

A MANUAL OF E L ECT ROTH ERAPY— Second Edition,
Thoroughly Revised — Arthur L. Watkins, M.D., Assistant
Clinical Professor of Medicine, Harvard Medical School;
Chief of Physical Medicine, Massachusetts General Hos-
pital: Medical Director, Bay State Medical Rehabilitation
Clinic, Boston, Mass. Lea & Febiger, Washington Square,
Philadelphia 6, Pa., 1962. 272 pages, 157 illustrations and
a plate in color, $5.00.

This second edition is being published four years after
the first edition. It is a basic introduction to one facet
of physical therapy called Electrotherapy. It reviews basic
physics and physiology, and application of the many
modalities in this field, including infra-red, ultraviolet,
low voltage currents for both stimulation and ion transfer,
diathermy, and ultrasound.

It is designed primarily for physical therapy students,
and those physicians who might need a basic reference
text in these fields.

The second edition updates the first edition, but actually
has not sufficient change in it to outdate the first edition.

It is an excellent text for those readers for whom it was
intended, mainly physical therapy students.

S. Malvern Dorinson, M.D.

* * *

THE MECHANISM OF ACTION OF WATER-SOL-
UBLE VITAMINS— Ciba Foundation Study Group No. 11

— A.V.S. De Reuck, M.Sc., D.I.C., A.R.C.S., and Maeve
O’Connor, B.A., editors for the Ciba Foundation. Little,
Brown & Company, Boston, Mass., 1962. 120 pages, $2.50.

This symposium on the Mechanism of Action of Water-
Soluble Vitamins presents interesting information concern-
ing the complex structural nature of the form in which
certain water soluble vitamins and their fractions are
mobilized for action. The designs and structural formulae
of the compounds and their intermediaries illustrates the
advanced stage of current biochemistry. The major in-
gredients of the devices are enzymes without which the
reactions could not proceed. What was a simple statement
of biochemical “fact” 25 years ago turns out to be an
exceedingly complex and often occult physicochemical and
thermodynamic reaction. It is amazing to contemplate the
wisdom of the pioneers who by means of simple biologic
observations were capable of knowing so precisely and
inferring so accurately the interdependence of these phenom-
ena, the comprehension of which transcends the ability
of all save those, all too few, who are actively working in
the mechanistic field of modern biochemistry.

S. P. Lucia, M.D.

VOL. 97, NO. 3

SEPTEMBER 1962

199

PROGRESS IN MEDICINAL CH EM ISTRY— Volume 1—

Edited by G. P. Ellis, B.Sc., Ph.D., F.R.I.C., Research De-
partment, Benger Laboratories Limited, Holmes Chapel,
Cheshire; and G. B. West, B. Pharm., D.Se., Ph.D., School
of Pharmacy, University of London. Butterworth, Inc.,
7235 Wisconsin Avenue, Washington 14, D. C., 1961. 262
pages, $11.25.

The topics covered in this review are Pharmacological
Screening Tests, Hypotensive Agents, Tranquillizers, Diu-
retic Drugs, Oral Hypoglycemic Drugs and Antifungal
Agents, the manuscripts having been completed between
January and April, 1960. The information for inclusion in
each chapter has been chosen with rare discrimination,
based on each author’s familiarity with his subject, and
although the book is the work of several authors, its style
is uniformly lucid and interesting, making it a delight to
read. In their preface, the editors state that this “collection
of reviews is written for the chemist, biochemist, pharma-
cologist, and to a smaller extent, the clinician.’’ Although,
therefore, not intended primarily for the clinician, the prac-
titioner can read the book with much profit, for it is a guide
to his understanding of the principles and procedures in-
volved in product development by the pharmaceutical
industry and by university laboratories, thus affording him
a better perspective on which his choice of drugs may be
based.

Each chapter has an excellent bibliography.

Clinton H. Thienes, M.D.

* * *

FINANCING MEDICAL CARE— An Appraisal of For-
eign Programs — Edited by Helmut Schoeck. Current com-
mentaries on medical care systems in seven foreign coun-
tries written by economists, actuaries, political analysts,
physicians, professors of medicine, and statesmen. The
Caxton Printers, Inc., Caldwell, Idaho, 1962. 314 pages,
$5.50.

One need not go beyond the borders of our northern
neighbor — Canada — to witness the pressures being exerted
by local and national governments on this continent to enact
compulsory health insurance for various segments, or whole
sections, of the population. In the United States, as in
provinces of Canada, the widespread enrollment under vol-
untary health insurance and the variety of measures adopted
by agencies on all levels of government to provide for the
health needs of the indigent have failed to deter legislative
proposals for one form or another of State or Federal health
insurance. (As this review is written, Saskatchewan’s com-
pulsory health insurance program has just gone into effect.)
Not infrequently, the experiences of European countries are
cited as examples of the “backwardness’’ of America in
this arena of controversy which has become the most explo-
sive social and political issue of the day. With the publica-
tion of this collection of articles, Professor Schoeck has
brought together in one reference source descriptions of
health insurance systems in seven European countries. In
so doing, he has had the assistance of economists, political
analysts, administrators, physicians, and other experts who
have had intimate experience with the programs in their
own countries. The book lives up to its promise of not being
impartial; for the editor and the contributors share a com-
mon belief in individual and voluntary efforts which are the
very antithesis of the philosophy underlying “state medi-
cine.”

This volume will serve as a timely reference for all those
who have supported the medical profession’s opposition to
Forand-King-Anderson — and variations yet to come. It will
be an aid to physicians who frequently have been confronted
with facts for which they lacked information to evaluate.
It will undoubtedly have a sobering effect upon those pro-
tagonists who equate medicine’s opposition purely with
“selfish” motives. Above all, it presents in simple and con-

cise language the background, origin, and present stage of
development of seven programs, some of the problems they
have attempted to resolve, and those which they have
created.

Although the systems of health care in Austria, Australia,
Germany, Great Britain, France, Sweden, and Switzerland
vary with respect to their causes, objectives, and scope and
extent of coverage, they reveal the different forms which
centralized government can utilize. They portray the effects
of different philosophies at different periods in the history
of each country. The reader will find the article on “Medical
Care for Youth . . .” in West Germany particularly in-
triguing in the light of the controversy over medical care for
the aged in the United States. The article on the develop-
ment of compulsory health insurance in Sweden is probably
the most illuminating and well-written of all since it con-
tains data and information which lend support to the
author’s arguments. It is unfortunate that some of the other
articles lack comparable statistics, but their conviction of
purpose and the insights they provide compensate in some
measure for this shortcoming.

The volume concludes with two articles which describe
the National Health Service in Australia, a system of vol-
untary-oriented health insurance which has been described
by Sir Earle Page in other medical periodicals. It is one
which the medical profession in Australia actively endorses
and supports, and one which undoubtedly would have con-
siderable appeal to the majority of physicians in this coun-
try who are faced with the alternatives before them. It is cer-
tainly the envy of the medical profession in Great Britain.
* * *

DRUG THERAPY— Frank C. Ferguson, Jr., M.D., Pro-
fessor of Pharmacology and Chairman of the Department
of Pharmacology, the Albany Medical College of Union
University, Albany, New York. Lea & Febiger, Washing-
ton Square, Philadelphia 6, Pa., 1962. 411 pages, $7.50.

This book is a compendium of the author’s personal
opinions about drugs and their clinical use. He has pro-
vided a list of the compounds which he considers most effi-
cient and least toxic and expensive, in variety sufficient to
cover all therapeutic needs. He has usually discussed more
than one compound in a class but has avoided duplication
as much as possible. When several drugs (which he con-
siders of equal value) exist, he has made a choice on the
basis of the manufacturer, favoring products of the com-
panies with the best practices.

Doctor Ferguson has included some 50 chapters in Drug
Therapy, listed in ten general groups of drugs, such as
anesthetic agents, anti-infective agents, compounds for the
cardiovascular system, for the central nervous system, and
for the endocrine system. Most chapters begin with general
notes describing features of activity, toxicity and metabo-
lism. Under “choice of drugs” are listed the ways in which
agents differ. Under “clinical usage” indications for use and
principles of dosage are described. Finally, specific drugs
are listed under generic names with representative trade
names for reference.

Since this is a small book, the author has excluded all
material not directly pertinent to clinical therapy. Relations
of chemical structure to activity have been excluded. Pho-
netic spelling and abbreviations are frequently used. No
references are given.

The reviewer finds Drug Therapy a volume which can be
very helpful and furnish valuable guidance to the practic-
ing physician, house officer, and student. It is, of necessity,
incomplete and may well produce cries of anguish from
manufacturers whose products are not listed. It is recom-
mended as a practical guide for the office desk or the med-
ical bag.

Edgar Wayburn, M.D.

200

CALIFORNIA MEDICINE

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The stimulus which initiates the defeca-
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Taken regularly, Metamucil tends to cor-
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Metamucil is available as Metamucil
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cartons of 16 and 30 single-dose packets.

1. Best, C. H., and Taylor, N. B.: The Physiological Basis
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Drs. Sidney Cohen and Keith S. Ditman said the
recent appearance of the drug as an item of under-
world traffic is “an alarming development.”

Now that the drug has become available from
sources concerned solely with the profits from illicit
sales, they said, physicians may encounter patients
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ciated with misuse of the drug include suicide,
prolonged psychotic reactions and antisocial be-
havior, they said.

There is illicit trade in LSD tablets, ampules and
saturated sugar cubes, they said.

Some persons who take marihuana also take LSD
and hold “LSD parties,” they said.

“Occasional catastrophic reactions can be antici-
pated from such casual, unattended use,” the two
physicians warned.

The visual and mental distortions caused by the
drug can be “a devastating experience” without the
“saving knowledge” that they are drug-induced and
temporary, they said. It is “not unlikely” that self-
destruction or psychotic reactions may follow such
an experience, they said.

Accidental ingestion of the drug by individuals
who are unaware of its nature has already occurred,
the authors said. A child who inadvertently con-
sumed a drug-saturated sugar cube remained par-
tially disoriented a month later, they said.

Addiction to LSD-25 has not yet been observed,
they said. However, they said, a “new but not rare”
type of multihabituation is appearing in which per-
sons frequently indulge in a variety of stimulants,
naroctics, sedatives, and hallucination-producing
drugs, including LSD.

One patient, who said she and her “beat” friends
regularly take one or another of eight different
kinds of drugs, claimed that withdrawal symptoms
for any single drug do not occur, they said.

LSD’s ability to produce hallucinations was dis-
covered 20 years ago, the physicians said. Since
that time, nearly 1,000 articles have been published
on the drug, they said. However, they said, the
manufacturers have refused to introduce the drug
commercially until its side effects are more precisely
determined.

At the present time, LSD-25 is distributed only
to those who wish to engage in scientific investiga-
tions, the authors said. Properly used the drug may
aid in the study of mental processes, they said.

“Its ability to induce a ‘model psychosis’ makes
it an excellent laboratory device for the study of
psychotic-like phenomena,” they said. “LSD-25 has
also been employed as an adjunct to psychotherapy
because recall of repressed memories is enhanced
and ego defensiveness to conflict-laden material is
reduced.”

The authors are affiliated with the Veterans Ad-
ministration Hospital and the University of Califor-
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The massive Bay Area onslaught against polio-
myelitis, scheduled to begin September 23, has been
given an official name by the doctors of the County
Medical Societies who are spearheading the pro-
gram. The ambitious undertaking to immunize up
to 3.500.000 people will be called the K. O. POLIO
program.

Dr. Edward B. Shaw, chairman of the Bay Area
Medical Association Committee, which is coordinat-
ing the program, announced the name and stated
that it was selected because it suggests that the
Sabin oral vaccine will provide a final “knock-out
blow” to all types of paralytic polio.

It is expected that 90 per cent or more of the
total population in this area will visit polio centers
on September 23, November 4 and December 9 to
eat a lump of sugar with the vaccine on it. This will
be the largest mass vaccination effort in the history
of the West, and probably the nation.

Polio centers will be set up in schools and other
community locations throughout the Bay Area. Each
person should take the vaccine on all three Sundays,
according to Dr. Shaw, because each dose immun-
izes against one type of paralytic polio.

People of all ages, from 3 months to the eldest
citizen, should take the thoroughly tested Sabin
(Continued on Page 72)

RALEIGH HILLS
HOSPITAL*

Member of the American Hospital Association
Recognized by the American Medical Association

EXCLUSIVELY for the TREATMENT of

ALCOHOL ADDICTION

by Conditioned Reflex and Adjuvant Methods

MEDICAL STAFF:

John R. Montague, M.D. Merle M. Kurtz, M.D.
Norris H. Perkins, M.D.

John W. Evans, M.D., Consulting Psychiatrist

ADMINISTRATORS:

Larrae A. Haydon Jean B. Tanner

RALEIGH HILLS HOSPITAL

6050 S.W. Old Schools Ferry Road
Portland 7, Oregon
Mailing Address: P. O. Box 366
Telephone: CYpress 2-2641

♦FORMERLY RALEIGH HILLS SANITARIUM. INC.

CALIFORNIA MEDICINE

I^\dramatic results with

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the classic antinauseant

MPULS (FOR I.M. OR I.V. USE)/SUPPOSICONES®/LIQUID/TABLETS

esearch in the Service of Medicine searle

Patient Stays Conscious During
External Heart Massage

An unusual case of a man who remained con-
scious while undergoing closed-chest massage to
restart his heart is reported in the August 4 jour-
nal of the American Medical Association.

The case was described by Dr. George M. Bernier,
department of medicine. University Hospitals of
Cleveland.

It is “much more common” for a patient to be in
a coma during and after external heart massage.
Dr. Bernier said. The comatose state is believed
to be caused by a marked reduction in the flow of
blood, and consequently the oxygen supply, to the
brain, he said.

However, the 63-year-old patient who did not go
into a coma had lived for two years with a pulse
rate of 20 to 40 beats a minute, be said. The normal
range is 67 to 72 beats a minute.

“It is possible that the cerebral blood flow obtained
during closed-chest massage in this man did not
differ much from his usual state,” Dr. Bernier said.

There is no information as to whether a chronic,
mild lack of oxygen can result in decreased oxygen
needs of brain tissue, he said, “but it may be that
an adaptive mechanism allows more effective utili-
zation of oxygen.”

Dr. Bernier said he felt the case illustrated the
effectiveness of external heart massage in main-
taining blood flow to the brain.

The patient had had a heart condition for several
years and was in the hospital when his heart stopped
beating, according to the case report. Four minutes
after closed-chest massage was begun, his respira-
tion became normal and he was conscious through-
out the 35 minutes the procedure was continued, it
said. The patient was discharged from the hospital
within a month and a year later was working at a
part-time job, it said.

"K. O, POLIO" Is Name for Fall
Polio Immunization Program

(Continued from Page 60)

vaccine. Dr. Shaw also points out that everyone
should take the vaccine regardless of having re-
ceived Salk polio shots because the Sabin oral vac-
cine gives added protection and makes it impossible
for a person to be a “carrier” of the disease.

The K. O. POLIO organization is now being
formed. Thousands of volunteers are being sought
to help in carrying out the program, and in educat-
ing the public regarding it.

When treatment for

is indicated

DHL

ANDROGEN- THYROID -COMBINATION

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in tivo convenient dosage forms

ANDROID ANDROID H.P.

(High Potency)

Each yellow tablet contains:

Each orange tablet contains:

Methyl Testosterone . .

. .2.5 mg.

Methyl Testosterone . .

....5 mg.

Thyroid Ext. (1/6 gr.) .

. . . 10 mg.

Thyroid Ext. (1/2 gr.) .

...30 mg.

Glutamic Acid

. . . 50 mg.

Glutamic Acid .......

Thiamine HCI

. . .10 mg.

Thiamine HCI

Indications: Impotence in male.

Average Dose: One tablet three times daily.

Available : Bottles of 100 and 500 at your pharmacy.

Caution : Not to be used when testosterone is contra-indicated.

Federal law prohibits dispensing- without prescription.

1. Methyltestorone-Thyroid in Treating Impotence, A. S. Titeff, General
Practice, Vol. 25, No. 2, Feb., 1962, pp. 6-8.

2. Thyroid-Androgen Relations, L. Heilman, et al.. The Jrl. of Clin. Endo-
crinology and Metabolism, August 1959.

Write for samples and literature . . .

(broVINEI the brown pharmaceutical company

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CALIFORNIA MEDICINE

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Dosage: Usual starting dose is 1 tablet q.i.d.
When necessary, this may be increased gradu-
ally up to 3 tablets q.i.d. With establishment of
relief, the dose may be reduced gradually to
maintenance levels.

Composition: 1 mg. 2-diethylaminoethyl benzi-
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mg. meprobamate.

Supplied: Bottles of 50 light-pink, scored tablets.

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GEM-FOAM

Topical Anesthetic & Analgesic

Now, prompt relief in acute and
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Indicated in: osteo and rheumatoid
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ger-o-foam combines methyl
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References: Gordon, E. E., and
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217, 1959.

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Dept. 106, Floral Park, New York

No Proof Body Stores
Surplus Protein

Scientific evidence does not support the theory
that the body stores surplus protein in the way it
stores sugars, starches and fats for emergency de-
mands, according to an article in the August 25
Journal of the American Medical Association.

Protein is a “currently glamorous nutrient” and
enthusiasm for protein food is widespread in the
United States today, L. Emmett Holt Jr., M.D., and
Elias Halac Jr., M.D., New York City, and Charlotte
N. Kajdi, A.B., Baltimore, wrote in the Journal.

A major factor in encouraging a liberal protein
intake is the concept that “reserve protein” can be
built up in advance to offset protein shortages that
may develop later due to privation or illness, they
said.

However, they said, “the data upon which this
concept rests are susceptible to different interpreta-
tions,” and “one must conclude that the existence
of protein stores has not been established.”

The researchers reported the results of two studies
they conducted to determine if a protein surplus en-
abled rats to withstand a subsequent deprivation of
protein.

In the first study, there was no difference in sur-
vival between a group of rats fed a moderate pro-
tein diet and then deprived of protein and a group

(Continued on Page 33)

SEEKS PHYSICIANS

for Psychiatric and General Medical
assignments in State facilities of the De-
partments of Mental Hygiene, Correc-
tions, Youth Authority.

Offering liberal salaries, a variety of
professional placement, and selection of
locale. No written examination. Inter-
views in San Francisco and Los Angeles
twice monthly.

Write for details to:

Medical Personnel Services,

Dept. SS,

State Personnel Board,

801 Capitol Avenue,

Sacramento, California

CALIFORNIA MEDICINE

:ience for the world's well-being®

PFIZER LABORATORIES Division, Chas. Pfizer & Co., Inc. New York 17, New York

IN BRIEF \Jhe dependability of Terramycin
in daily practice is based upon its broad range of
antimicrobial effectiveness, excellent toleration,
and low toxicity. As with other broad-spectrum
antibiotics, overgrowth of nonsusceptible organ-
isms may develop. If this occurs, discontinue the
medication and institute appropriate specific
therapy as indicated by susceptibility testing.
Glossitis and allergic reactions to Terramycin
are rare. For complete information on Terra-
mycin dosage, administration, and precautions,
consult package insert before using.

More detailed professional information avail-
able on request.

Boutonneuse fever is a tick-borne, acute, febrile
disease often affecting children. The bite site
becomes a small, necrotic ulcer. A striking mac-
ular or maculopapular eruption develops on the
trunk, palms and soles. Onset is sudden, with
chills, high fever, violent headache and lassitude.
The high temperature — up to 103’ F.— charac-
teristic of both boutonneuse fever and broncho-
pneumonia, drops rapidly following initiation
of Terramycin therapy.

I'c

to bronchopneumonia in California

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Safest Color for Car
Is Blue and Yellow

From the standpoint of motoring safety, studies
indicate that blue and yellow are the best car colors.

In fact, a two-tone blue and yellow automobile
appears to be one of the safest combinations, ac-
cording to an article in the September Todays
Health magazine, published by the American Medi-
cal Association.

The color of an automobile can mean the differ-
ence between life and death, the article said.

Studies at the University of California at Los
Angeles, it said, showed that the color of an ap-
proaching automobile definitely influences a driver’s
judgment of how far away it is.

“Judged from a distance of 200 feet, objects of
some colors appeared to be up to six feet closer than
objects of other colors,” the article explained.

“And the investigators point out that under aver-
age conditions, a distance of six feet in judging
distance may easily mean the difference between a
serious accident and no accident.”

Of the various colors tested on 164 subjects, blue
and yellow made distant objects seem closest — under
both daytime and night-time conditions, the article
said. Gray shades made objects appear to be the
farthest away, it said. Blue was ranked safest in
daylight and fog, it said, and yellow safest at night.

Colors have both a physical and psychological
effect, the article pointed out.

Red, green and blue have a very definite physical
effect, it said.

Tests show that when red predominates in a
room it increases blood pressure, quickens muscular
reactions, excites emotions, tends to produce rest-
lessness, and makes time appear to pass much more
slowly, it said. On the other hand, green has been
shown to have a calming effect, it said, and time
tends to slip by faster for a person in a blue room.

Happiness also can be linked to room color, the
article said. Persons surrounded by dull gray walls
experience monotony, fatigue, headache, discontent,
irritability, and hostility, it said, while those in a
colorfully decorated room had feelings of comfort
and well-being.

The most depressing colors are black and gray,
the article continued, and the most uplifting are
those which predominate in nature.

Women are more affected by color than men, it
said, and psychologists believe persons who dislike
color, or fail to respond to it are emotionally re-
pressed.

“Experiments conducted at the Drexel Institute of
Technology, Philadelphia, have shown that those
whose wardrobes feature a variety of color tend to
be much better balanced emotionally than persons
whose attire is drab,” it said.

The article was written by John E. Gibson.

CALIFORNIA MEDICINE

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A 5,000 USP Units

D 500 USP Units

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B, 2.5 mg.

B2 2.5 mg.

B4 0.5 mg.

B j2 1 meg.

Niacin and Niacinamide 15 mg.

d-Calcium Pantothenate 5 mg.

E 0.15 I.U-

Yeast and desiccated liver are added
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Complex factors.

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Iron 7.5 mg. Potassium 2.5 mg.

Magnesium 2.5 mg. Zinc 0.15 mg.

The Stuart Formula is available as a pleasant tasting liquid

REFERENCES

AND REVIEWS

Radiation Breakage of Human Chromosomes in Vivo
and in Vitro — A. Norman, R. E. Ottoman, and R. C.
Veomett, Radiology, 79:115 (July) 1962.

Chromosomes in the leukocytes from the peripheral blood
were examined before and after irradiation in vivo and in
vitro to determine the immediate effect produced. While the
data obtained are admittedly preliminary and subject to
some uncertainties of technique and interpretation, the ra-
diosensitivity of human chromosomes was demonstrated by
their fragmentation following exposure to irradiation.

* ❖ *

Stereoscopic Televised Fluoroscopy — H. M. Stauffer,
G. C. Henny, and A. W. Blackstone, Radiology, 79:30
(July) 1962.

The operation of an experimental televised stereoscopic
fluoroscopy system is described. Pulsed operations of two-
image orthicon television chains is employed to separate the
right and left eye images for presentation to monitors viewed
with polaroid glasses. Application in selective catheteriza-
tion procedures in infants anil experimental animals and in
foreign-body extractions from the lung is anticipated.

Ventilatory Function in Normal Children — R. M. Cher-
niack, Canad. Med. Assn.. 87:80 (July 14) 1962.

Vital capacity (VC), maximum breathing capacity
(MBC), and maximal midexpiratory flow rate (MMF)

were determined in 260 male and 261 female normal chil-
dren whose ages ranged between 3 and 17 years, and whose
height ranged between 70 and 210 cm. Relationships of
these measurements of pulmonary function to age and body-
size were sought, and regression equations were obtained
for calculating VC, MMF, and MBC from age and height.
Nomograms for predicting normal values are presented.

Postmortem Examination of Pulmonary Veins — H. R.
Bates, Jr. Amer. J. Clin. Path. — Vol. 37:639 (June) 1962.

A simple method is described for in situ examination of
the major pulmonary veins at autopsy.

❖ ❖ ❖

Methohexital Sodium — C. P. Wangeman. Anesth. Analg.
Vol. 41:307 (May-June) 1962.

Methohexital sodium is a new ultrashort-acting oxybarbi-
turate 2% times as potent as thiopental sodium, but with
a very short recovery period and minimal aftereffects. A
description of a simple method of continuous administration
of the drug and an account of the author’s experiences
during 427 surgical operations of all kinds are included.
This agent has special value (1) as a means of producing
controlled sedation during regional anesthesia and (2) as
an anesthetic agent in the poor risk patient.

* * *

Chemical Mediators of Acute Allergic Reaction — G. B.
Logan, Amer. J. Dis. Child., 104:185 (Aug.) 1962.

The acute allergic reaction is probably mediated by phar-
macologically active substances that are formed in the body,
where they exist in a “pro” form, or result from cellular in-
jury by antigen-antibody assault. Either an antigen-anti-
body reaction or other stimuli release these substances to
(Continued on Page 38)

AT HERRICK MEMORIAL HOSPITAL • 2001 DWIGHT WAY • BERKELEY 4, CALI FORN IA

A NEW HOSPITAL ATTACHED REHABILITATION CENTER

FOR PATIENTS HAVING

• Cardiovascular Accidents • Arthritis

• Spinal Cord Injuries • Industrial Injuries

• Amputations • Speech & Hearing Problems

• Congenital Deformities

THE CENTER OFFERS

• Physical & Occupational Therapy • Social Service

• Speech & Hearing Therapy * Hubbard Tank

• Inpatient Care • Self Care • Outpatient Care

THE REFERRING DOCTOR CONTINUES IN COMPLETE CHARGE OF HIS PATIENT

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is a new chance at living!

CALIFORNIA MEDICINE

Trocinate

Brand of Thiphenamil HC1.

FOR DIVERTICULITIS, MUCUS COLITIS,
IRRITATIVE DIARRHEA, IRRITATIVE URETERITIS,
BLADDER SPASM

J^rocinate is a musculotropic antispasmodic with
no appreciable anticholinergic action. It relieves
spasms of the lower bowel and genito-urinary
tract by direct action on the contractile mech-
anism of smooth muscles. The absence of any
appreciable action on the autonomic nervous
system eliminates the usual side-effects. It may
be safely used in glaucoma. Each tablet con-
tains 100 mgs. Trocinate HC1.

Usual Dosage : 2 tablets, 4 times a day. Main-
tenance dosage is frequently lower.

Dispensed in bottles of 40 and 250 tablets.

WM. P. POYTHRESS & COMPANY, INC., RICHMOND, VIRGINIA

Manufacturers of ethical pharmaceuticals since 1856

Advertising • OCTOBER 1962

A.M.A. Issues Revised
First Aid Manual

Since the beginning of World War II, when first
aid became for a time a classroom subject in many
schools, the art of doing what’s right at the time
of an injury has evolved in step with medicine itself.

Consequently, what used to be considered good
practice when dad was a boy is often no longer
recommended by medical authorities. Some of the
old-style first aid procedures, in fact, have been
found to be more injurious than the injury itself.

The most up-to-date list of dos and don’ts for
handling the more common variety of emergencies
has been issued by the American Medical Associa-
tion in a 48-page pocket-size first aid manual. Sub-
ject matter ranges from cuts to childbirth and from
scorpion stings to mental disturbances.

“It is a digest of the best knowledge available on
the subject at this time,” said Dr. Raymond L.
White, director of the A.M.A.’s Division of En-
vironmental Medicine, which published the booklet.
It succeds an earlier manual first published by the
A.M.A. in 1952.

Among the newer first aid concepts recommended
and illustrated in the manual are techniques for the
control of severe bleeding and artificial respiration.

Heavy bleeding resulting from cut blood vessels
can best be stopped by applying pressure directly

over the wound, rather than employing some of the
older methods, the manual stresses. A clean cloth
is preferred, but if all else is lacking the bleeding
can be stopped with direct pressure from the hand
or fingers. Stopping blood at the so called “pressure
points,” which first aiders used to learn by rote, is
ignored and in red letters the booklet spells out:
“Never use a tourniquet to control bleeding except
from an amputated, mangled or crushed arm or leg.”

As for artificial respiration, the booklet recom-
mends the new mouth-to-mouth technique and illus-
trates its use with both adults and youngsters,
although it also contains information on a manual
method when mouth-to-mouth breathing is impos-
sible.

Among other subjects discussed are shock, trans-
porting the wounded, epileptic seizures, massive
wounds of the body, poisoning, burns, sprains and
strains and special wounds.

A section lists emergency first aid supplies, most
of which can be found in the average household,
and which include only three “medicines” — mild
soap, baking soda and table salt.

The new manual was prepared by the A.M.A.’s
Council on Occupational Health and the Department
of Health Education. Many of the recommendations
were made by physicians who by the nature of their
work are most often confronted with such emer-
gencies.

ENDOCRINOLOGY IN GENERAL PRACTICE

THE HOUSE OF ETHICAL
PHARMACEUTICALS

We would like to take this opportunity
of inviting you to attend one of our highly
informative classes dealing with Endocrin-
ology in General Practice.

LANPAR COMPANY • • • 2727 W. MOCKINGBIRD LANE • • • DALLAS 35. TEXAS

CALIFORNIA MEDICINE

Milky Disinfectant Being
Taken As Medicine

A new poisoning hazard was reported in the
August 18 Journal of the American Medical Asso-
ciation.

A disinfectant containing hexachlorophene is be-
ing mistaken for milk of magnesia because of its
similar milky appearance, according to a Journal
article.

Ten cases in which hospital patients accidentally
swallowed the disinfectant were reported by Drs.
John B. Wear Jr., Madison, Wis., and Robert Shana-
han and Rigdon K. Ratliff, Ann Arbor, Mich.

The hexachlorophene solution is used prior to
surgery to clean the site of the operation, the authors
said, and in most of the poisoning cases, the dis-
infectant had been placed in the patient’s room in
a paper cup.

Taken by mouth, the solution causes stomach
irritation with vomiting and diarrhea, which, if
excessive, can dehydrate the body and lead to death
unless the patient is treated, they said.

To prevent such accidents, the authors said, hos-
pital personnel should never dispense the disinfectant
in a drinking container and the patient should he
warned not to drink it.

Furthermore, they said, the hospital or the manu-
facturer should be encouraged to add a coloring
substance to the solution so that it cannot be con-
fused with milk of magnesia or other medication.

No Proof Body Stores Surplus Protein

(Continued from Page 10)

of rats fed a high protein diet and then deprived
of protein, they said.

In the second study, the previous findings were
confirmed and it was found that the percentage of
protein in fat-free tissues did not differ significantly
between rats fed a normal protein diet and those
given a high protein diet, they said.

Thus, they said, neither study supports the con-
cept of protein stores.

The authors concluded that there is “no virtue
in feeding protein beyond the minimum adequate
quantity.”

Protein deprivation cannot be taken care of in ad-
vance, they said. As a general rule it is after the
event that shortages are made up, they said, adding:

“Nutritional requirements in convalescence are
very different from those in health. The convalescent
is a different animal. At this time he needs and
should have more protein than the minimal require-
ment for health.”

On the basis of short-term studies, they added,
there is no evidence that there is harm in giving
more protein than the minimum adequate require-
ment to healthy persons. However, the possibility
that long-term differences may occur cannot be de-
nied. they said.

Although large areas of the world are suffering
from protein deficiency, the researchers said, this
disorder is encountered only rarely in the United
States in a port or border city imported from a less
favored foreign country.

Reasonably good information exists on the mini-
mum requirements of a standard high-quality pro-
tein and a physician can ascertain whether a patient
is receiving adequate protein with some simple
tests, they said.

The authors are affiliated with the departments
of pediatrics of New York University School of Med-
icine and Johns Hopkins University.

Your 'public relations problem has been
our prime consideration in collection
procedures during two generations of
ethical service to the Medical Profession.

THE DOCTORS BUSINESS BUREAU

Since 1916

FOUR OFFICES FOR YOUR CONVENIENCE:

821 Market St., San Francisco 3 GArfield 1-0460

Latham Square Bldg., Oakland 12 GLencourt 1-8731

617 S. Olive St., Los Angeles 14 MAdison 7-1252

19 Pine Ave., Long Beach HEmlock 5-6315

RALEIGH HILLS
HOSPITAL*

Member of the American Hospital Association
Recognized by the American Medical Association

EXCLUSIVELY for the TREATMENT of

ALCOHOL ADDICTION

by Conditioned Reflex and Adjuvant Methods

MEDICAL STAFF:

John R. Montague, M.D. Merle M. Kurtz, M.D.
Norris H. Perkins, M.D.

John W. Evans, M.D., Consulting Psychiatrist

ADMINISTRATORS:

Larrae A. Haydon Jean B. Tanner

RALEIGH HILLS HOSPITAL

6050 S.W. Old Schools Ferry Road
Portland 7, Oregon
Mailing Address: P. O. Box 366
Telephone: CYpress 2-2641

♦FORMERLY RALEIGH HILLS SANITARIUM, INC.

Advertising • OCTOBER 1962

for your young patient with

• Emotional Problems

• Learning Difficulties

KINDERGARTEN THROUGH HIGH SCHOOL

DEVEREUX SCHOOLS IN CALIFORNIA

ROBERT G. FERGUSON, Ed.D., Director
KEITH A. SEATON, Registrar
KENNETH L. GREVATT, M.D., Medical Director
RICHARD H. LAMBERT, M.D., Psychiatric Director

You are invited to write
for our recent brochure.

Box 1079, Santa Barbara

THE
DEVEREUX
FOUNDATION

Devon, Pennsylvania
Santa Barbara, California
Victoria, Texas

FIFTY YEARS OF SERVICE TO CHILDREN

HELENA T. DEVEREUX EDWARD L. FRENCH, Ph.D.
Founder and Consultant President and Director

SCHOOLS

COMMUNITIES

CAMPS

TRAINING

RESEARCH

Heart Drug Used
For Glaucoma

Digitalis, long used for heart failure, has been
found to be useful in treating several types of glau-
coma, an eye disease which may lead to blindness,
Kenneth A. Simon, M.D., and Sjoerd L. Bonting,
Ph.D., Bethesda, Md., report.

Writing in the August A r chives of Ophthalmology,
published by the American Medical Association, the
two researchers said digitalis had been used to treat
16 patients with chronic simple glaucoma and five
patients with congenital and juvenile glaucoma.

Digitalis alleviates the main characteristic of
glaucoma, intense pressure within the eye, by re-
ducing production of the fluid which fills the eye
cavity, they said. The drug inhibits an enzyme in-
volved in the formation of the fluid, cutting fluid
producion by 45 per cent, they said.

This is comparable to the effect produced by
acetazolamide, the drug currently used to reduce
ocular pressure in glaucoma, the authors said. Digi-
talis could be used when side-effects or sensitivity
precludes the use of acetazolamide, they said.

The researchers are affiliated with the Ophthal-
mology Branch, National Institute of Neurological
Diseases and Blindness, National Institutes of Health.

COOK COUNTY

graduate school of medicine

CONTINUING EDUCATION COURSES
STARTING DATES— FALL, 1962

Surgical Technic Two Weeks, Nov. 5

Surgery of Colon and Rectum One Week, Nov. 26

Vaginal Approach to Pelvic Surgery One Week, Dec. 17

Gynecology, Office & Operative Two Weeks, Nov. 5

Obstetrics, General & Surgical Two Weeks, Nov. 26

Urology Two Weeks, Oct. 29

Proctoscopy & Sigmoidoscopy One Week, Oct. 29, Dec. 17
Varicose Veins One Week, Oct. 29, Dec. 17

General Surgery One Week, Oct. 29

Advances in Medicine One Week, Oct. 15

Advances in Surgery One Week, Dec. 10

Blood Vessel Surgery One Week, Oct. 22

Board of Surgery Review, Part I Two Weeks, Nov. 5

Board of Surgery Review, Part II Two Weeks, Nov. 26

Diagnostic Radiology Two Weeks, Oct. 29

Basic Internal Medicine Two Weeks, Nov. 5

Management of Common Fractures &

Dislocations One Week, Dec. 3

Board of Infernal Medicine Review,

Part II One Week, Dec. 3

Information concerning numerous other continuation courses
available upon request.

TEACHING FACULTY:

Attending Staff of Cook County Hospital
ADDRESS:

REGISTRAR, 707 South Wood Street,

Chicago 12, Illinois

CALIFORNIA MEDICINE

SURBEXT

. ... in

ORAL

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Abbott’s
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Patients receive replenish-
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Each Filmtab® Surbex-T represents:

Thiamine Mononitrate (Bi).... 15 mg.

Riboflavin (B2) 10 mg.

Nicotinamide 100 mg.

Pyridoxine Hydrochloride 5 mg.

Cobalamin (Vitamin B12) 4 meg.

Calcium Pantothenate 20 mg.

(as calcium pantothenate racemic)
Ascorbic Acid (C) 500 mg.

(as sodium ascorbate)
Desiccated Liver, N.F. . . .
Liver Fraction 2, N.F. . . .
. . . and when needs are more
moderate, Sur-Bex® with C,
Abbott’s improved B-complex
formula with 250 mg. of C.

75 mg.
75 mg.

Filmtab— Film-sealed tablets, Abbott: U.S. Pat. No. 2,881,085

REFERENCES AND REVIEWS

(Continued from Page 26)

exert their actions in the patient, producing the varying
manifestations of the acute allergic reaction. The role of
histamine, 5-hydroxytryptamine (serotonin), acetylcholine,
slow-reacting substances of anaphylaxis, and bradykinin is
discussed, and an attempt is made to assess their impor-
tance. Heparin release is probably of significance only in
anaphylaxis in the dog.

Alcian Green: A Routine Stain for Mucins — F. A. Putt
and P. B. Hukill, Arch. Path., 74:169 (Aug.) 1962.

Alcian green is a specific stain for acid mucopolysaccha-
rides. The simplicity of its application recommends it as a
preferred method for epithelial and connective tissue mucins
in routine pathologic material. Two staining techniques are
described, one involving Kernechtrot and metanil yellow as
counterstain, the other involving the Verhoeff-van Gieson
elastic tissue method as counterstain. The second method is
useful in studying tumors, allowing the evaluation of mucus
production and vascular invasion in the same section.

Histological Study of Wound Washings for Tumor
Cells — M. Weinlos, G. R. Macdonald, and J. D. Taylor,
Canad. J. Surg., 5:278 (July) 1962.

Wound washes from 169 patients were obtained either
at operation or at autopsy and examined for tumor cells on
a double blind basis. The cellular material was stained with
hematoxylin-eosin and examined by a pathologist. Tumor
cells were found from (1) 25 per cent of patients with can-
cer and (2) 13 per cent of patients where cancer was
neither suspected nor subsequently found. Washes from
Group 2, where cells that appeared malignant were detected,

were termed “false positives.” Although tumor cells can be
isolated from wound beds, this study emphasizes the need
for better cytological techniques for the identification of
malignant cells.

❖ ❖ ❖

Detrusor Hypertrophy: Roentcenocraphic Detection
of Early Bladder Neck Obstruction — J. Edeken, G.
Strong, and A. Khajavi, Radiology, 79:88 (July) 1962.

A soft-tissue shadow, surrounding the contrast-filled blad-
der, was observed during intravenous urography in 40 of 57
patients with proved bladder-neck obstruction. This finding,
representing compensatory hypertrophy of the detrusor mus-
cle, is best demonstrated before decompensation has oc-
curred. The sign is usually lost when large amounts of
residual urine stretch and thin the previously hypertro-
phied bladder wall. The shadow has not been observed in
normal subjects.

Simple Gastric Biopsy: Experience with Crosby-Kugler
Capsule — M. H. Floch and T. W. Sheehy, Gastroenterol-
ogy, 43:32 (July) 1962.

Using the Crosby-Kugler capsule, 61 gastric biopsies were
performed on 40 patients. The procedure described yielded
diagnostic tissue in all but one instance. No episode of
perforation or bleeding was encountered by serial clinical,
hematological, or stool guaiac studies. The technique is safe
and rapid and causes little discomfort to the patient.

Urinary White Cell Excretion — P. J. Little, Lancet
1:1149 (June 2) 1962.

The urinary white cell excretion rate has been measured
in 50 women using a form of mid-stream sampling. The
(Continued on Page 46)

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CALIFORNIA MEDICINE

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REFERENCES AND REVIEWS

(Continued from Page 38)

results are similar to those obtained when the urine is col-
lected with a catheter. In addition, in 304 patients the
white cell excretion rate measured using a Fuchs-Rosenthal
counting chamber has been compared in the same urines
with the number of cells seen per high power field on exam-
ining the centrifugal urine deposit without a counting
chamber. Of 155 urines in which only 1 to 5 cells were
seen per high power field, 42 had abnormally high white
cell excretion rates. Some of these urines were infected.
❖ ❖ ❖

Behavior of Serum Quinine Oxidase in Diseases of
Liver — I. Ragno and I. Baldi, Riforma Med., 76:408
(April 14) 1962.

The study of quinine oxidase in liver disease was con-
ducted on 86 persons; 56 suffered from hepatopathies, 15
had other diseases, and 15 were considered healthy. Results
obtained showed that the reaction was not specifically con-
nected with proof of damage in the hepatic parenchyma. In
cases of acute hepatitis the reaction was intensely positive.
The test, therefore, should not be considered as specific in
revealing the existence or not of hepatic parenchymal dis-
order, but because of intense positivity observed in cases of
acute hepatitis, it should be considered as a useful test in
the differential diagnosis of hepatocellular jaundice and
jaundice due to cholestasis.

Chronic Calcific Pencreatitis in a Child — J. M. Batson
and D. H. Law, Gastroenterology, 43:95 (July) 1962.

A case of chronic calcific pancreatitis occurring in a child
is reported. Unusual manifestations of this case, including

presentation with ascites, a probable traumatic etiology, and
the rarity of this condition occurring in childhood are dis-
cussed and reviewed. Although pancreatic calcification is
seen on x-ray, the patient has developed normally and is
essentially asymptomatic after a three-year followup.

* * *

Combination Therapy of Malignant Hemangioendothe-
lioma with Radiation and Methotrexate — G. A. Hy-
man, F. Herter and R. Guttmann, Radiology, 79:6 (July)
1962.

The authors had an unusual opportunity to study 4 cases
of metastatic malignant hemangioendothelioma in the course
of one year. These were treated with methotrexate alone,
radiotherapy alone, and methotrexate and radiotherapy in
combination. The authors believe that radiotherapy as well
as methotrexate alone in adequate dosage will cause tumor
regression for periods as long as 10 months. They conclude
that the combination of the two agents yields the best re-
sults in the treatment of this rare and aggressive tumor.

% # *

Treatment of Carcinoma of the Endometrium — J. M.

Sala and J. A. del Reggato, Radiology, 79:12 (July) 1962.

A series of 242 cases of carcinoma of the endometrium
with a 100 per cent followup is reported. The absolute sur-
vival rates at 3, 5, and 10 years are 56 per cent, 46 per cent,
and 39 per cent respectively. No vaginal implants or metas-
tases were observed during the first three years of followup
of 118 patients treated by a combination of preoperative
radiotherapy and hysterectomy. The trend of the data favors
roentgenotherapy over curietherapy as the modality of
choice for the preoperative irradiation of carcinoma of the
endometrium.

DBI=TE)

CAPSULES 50 mg.

Brain Surgery Performed With Hypnosis

A brain operation performed with hypnosis pro-
viding the major part of anesthesia was reported in
the September 1 Journal of the American Medical
Association.

The operation was performed on a 38-year-old
man in Veterans Administration hospital, Indian-
apolis, to relieve epileptic attacks caused by an
accidental gunshot wound in the right forehead,
Drs. Som N. Nayyar, neurosurgeon, and John Paul
Brady, psychiatrist, Indiana University Medical
Center, Indianapolis, said.

Although there are some special difficulties asso-
ciated with the use of hypnotic suggestion as a
means of anesthetizing a patient, they said, hypnosis
has properties that make it preferable in certain
situations.

In this case, they said, the brain condition had
made the patient ‘"hostile, suspicious and rather
uncooperative.” General anesthesia was undesirable
because of the need to monitor the electrical activity
of the brain during the procedure, they said, and
with local anesthesia the patient’s disposition might
have proved to be a problem.

Therefore, hypnosis was chosen, they said. The
patient was hypnotized the night before the opera-
tion to provide sound sleep and relieve anxiety, they
said. The patient was rehypnotized before the opera-

tion with a suggestion of deep anesthesia of the
head region, they said. During the four and one-half
hour procedure, they said, only small amounts of a
local anesthetic and a pain-killing drug were needed.

Hypnosis provided “the best surgical conditions”
for this type of operation, the physicians said, and
perhaps the most important advantage was the re-
laxation, calm, and cooperation evidenced by a
previously difficult patient throughout a long and
anxiety-provoking brain operation in the awake state.

The authors said there apparently has been only
one previously published report of a brain opera-
tion being performed with hypnosis.

PHYSICIAN PLACEMENT SERVICE

of the

CALIFORNIA MEDICAL ASSOCIATION

The C.M.A. offers free placement assistance through the Phy-
sician Placement Service, 693 Sutter Street, San Francisco 2,
California. This service is for the use of all physicians seeking
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brand of sustained action phenformin HCI

first and only

timed-disintegration

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long term response. . .“Secondary failure is unlikely to occur” with phenformin-^
(DBI-TD capsules, DBI tablets). Phenformin has been successfully administered daily in
diabetics in one study for over 3 years2 and in another for up to AVz years1 with “a virtual
absence of acquired resistance or true secondary failure.”1 Indeed, DBI has produced a
satisfactory response in 55 to 60% of tolbutamide secondary failures.3.7

long term clinical safety ... No liver or parenchymal organ toxicity has been ob-
served after up to 2Vz years of daily use of DBI-TD — nearly 5 years with the DBI tablets.1-2.9
"The absence of hypoglycemic reactions” with phenformin “has been conspicuous.”3

long term tolerance . . . DBI-TD is well tolerated with minimal g.i. side effects.2.®.8
Radding et al.6 report, “the relative freedom from gastrointestinal side effects was particu-
larly reassuring . . . and in no instance was it necessary to discontinue the drug.”

long term convenience. . . Once a day dosage — or at most twice a day— -for
great majority of diabetics makes DBI-TD simple and convenient therapy. Each dose lowers
blood sugar gradually, smoothly, for about 12 to 14 hours.6

DBI-TD (brand of Phenformin HCI — Nl-0-phenethylbiguanide HCI) available as 50 mg. timed-disintegra-
tion capsules; bottles of 100 and 1000 capsules. Also available as DBI tablets, 25 mg., bottles of 100
and 1000.

Important: Before prescribing DBI-TD, the physician should be thoroughly familiar with directions for
use, including indications, dosage, possible side effects, precautions and contraindications. Write for
complete literature.

1. Pomeranze, J.: Clinical Med. 8:1155, June 1961. 2. Krall, L. P. and Bradley, R. F.: Geriatrics 17:337, May
1962. 3. DeLawter, D. E. et al.: J.A.M.A. 171:1786. Nov. 28, 1959. 4. Perkin, F. S.: J.A.M.A. 173:36, May 7,
1960. 5. Pearlman, W.: Phenformin Symposium, Houston, Feb. 1959. 6. Radding, R. S. et al.: Metabolism
11:404, April 1962. 7. Gold, A. et al.: Applied Therapeutics 2:137, 1960. 8. Brown, G. D. and Gabert, H.:
Applied Therapeutics 4:451, May 1962. 9. Gold, A.: Applied Therapeutics 4:466, May 1962.

u.s. vitamin & pharmaceutical corp.

Arlington-Funk Laboratories, division • 800 Second Avenue, New York 17, N. Y.

Orinase dosage 1 Gr.

Mrs. C. S., a youthful 50-year-
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diabetic, and so is her daughter.
In November 1956, she was
transferred to Orinase after 16
years on insulin. Following a
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at 2 Gm. daily.

Mrs. S. has no need for
increased Orinase in the
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she can and often does
arrange for impromptu
entertainment at her home
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OFFICIAL JOURNAL OF THE CALIFORNIA MEDICAL ASSOCIATION
(£) 1 962, by the California Medical Association

Volume 97

OCTOBER 1962

Number 4

Newer Concepts in Relation to Hypertension

LOUIS N. KATZ, M.D., Chicago

Are there really any new concepts in the area of
hypertension or are today’s views merely a matter
of emphasis of what has been known for many
years ?

Clinical handling of hypertension has advanced
greatly in the past 30 years. Hypertension, at the
same time, has been increasing in frequency. This
increase has been greater for secondary hyperten-
sion than for primary (essential) hypertension
since in a greater proportion of cases a known
cause has been revealed — be it pyelonephritis or re-
nal vascular occlusion, the most frequent causes, or
coarctation of the aorta, pheochromocytoma, Cush-
ing’s disease, adrenal tumors, primary aldostero-
nism or polycystic kidney. With this separation of
the secondary from the primary form have come
better methods of diagnosing the known causes and
improved methods of medical and surgical therapy.

At this point it should be noted that the identifi-
cation of a possible etiological cause for hyperten-
sion does not per se prove that it is the cause. The
proof ultimately rests upon the demonstration that
removal of the “cause” relieves the hypertension.
Circumstantial evidence that the hypertension was
produced by the suspected factor even though the
elevated blood pressure is no longer dependent upon
it is obviously less convincing. However, this possi-
bility cannot be excluded since such independence

Cardiovascular Institute, Michael Reese Hospital and Medical Cen-
ter, Chicago 16.

Presented as part of a Panel on New Approaches and Treatment
of Hypertension at the 2nd General Meeting at the 91st Annual Ses-
sion of the California Medical Association, San Francisco. April 15
to 18, 1962.

of its primary cause has been shown to occur in ex-
perimental renal hypertension: Removal of an
ischemic kidney soon after hypertension develops
will restore the blood pressure to normal, whereas
removal at later dates will not. Furthermore, not all
patients with renal vascular occlusion and pyelone-
phritis have hypertension.

Even without any final decision as to the cause
of primary hypertension, its natural history and its
demonologic features have been made clearer and
some glimmerings of the role of hereditary and
environmental factors, both physical and psycho-
logical, have been obtained. More important, ac-
celerated (malignant) hypertension has been more
clearly delineated from so-called benign hyperten-
sion, and drug and surgical therapy in handling all
forms of hypertension has advanced greatly. Today
there is available a vast array of hypotensive drugs
and surgical procedures which will lower blood pres-
sure, if only the physician has the wisdom to choose
properly among them and, more important, to know
when they should be used.

Once again, practical therapy has outpaced con-
ceptual knowledge, and empiricism still reigns over
much of the practical handling of hypertension. I
stress this last point to emphasize that momentary
fashions in concept should not sway the practicing
physicians too much. It is his task to pick out the
kernels and discard the chaff. One does not treat
hypertension any more than one treats an electro-
cardiogram or fever or high blood cholesterol (ex-
cept, as in cases of excessively high fever or blood
cholesterol, where one tries to lower the level be-

VOL. 97, NO. 4 • OCTOBER 1962

201

cause there is an instinctive abhorrence of a wide
shift from what is considered to be the normal).

When should one treat hypertension? I think all
will agree that accelerated (malignant) hypertension
should be treated when recognized, and even when
it is anticipated. The evidence is clear that longevity
with comfort has been increased in such cases. I
think one should treat benign hypertension when the
risk of clinically manifest atherosclerosis is great.
Other means of therapy, including diet, are as im-
portant as hypotensive therapy in hypertensive pa-
tients with a proclivity to ischemic heart disease.
This is true to a lesser extent in cerebrovascular
disease, for in a large proportion of such cases the
condition is due to hypertensive vascular disease un-
accompanied by atherosclerosis. When these dreaded
sequelae of hypertension are excluded, the indica-
tions for hypotensive therapy in primary benign
hypertension are ill defined. Hypotensive drug ther-
apy is probably employed far too often, many pa-
tients, who are not really benefited, being made
uncomfortable or even harmed by the creation of
unwanted side effects or iatrogenic heart disease.
What applies to primary benign hypertension ap-
plies also to benign secondary hypertension except
that here the possibility of removing the cause,
when feasible, should be seriously considered in
terms of expected benefit in comfort and longevity
as against the risk and complications of surgical
operation.

Hypertension is pathogenically multifaceted. The
nervous system is involved in hypertension. This
involvement includes afferent nerves from many
external and internal sensors, the latter being in
part homeostatic; it also includes the complex cen-
tral nervous system cybernetic apparatus, with neu-
rons located in the hypothalamus, thalamus, limbic
areas and cerebral cortex. All of these impulses ulti-
mately reach the final common paths in the efferent
nerves to the systemic arterioles (and doubtlessly
the venules) and the heart. It is also possible that
some of these impulses act by way of efferent nerves
to the kidney, its vasculature, its excretory apparatus
or its secretory portion, notably the juxtaglomerular
apparatus where renin is formed. It is also likely
that some impulses act by way of efferent nerves to
the endocrine glands, notably the adrenal medulla
and cortex and the anterior and posterior pituitary.

Through these several paths to the kidneys and
other endocrine glands, a number of factors interact
by way of the hormones they secrete and by their
effect on the electrolytes and water content of the
body to readjust their several rates of activity. The
end result is to adjust and maintain the blood pres-
sure. Any number of feedback mechanisms are set
up in this way to keep the blood pressure constant.
It is the very complicated multichanneled mecha-

nism which I wish to stress rather than the domi-
nance of any one over the other in considering the
pathogenesis of hypertension.

There is some evidence to suggest the importance
of the nervous system, operating through the mecha-
nism of conditioning, in hypertension. The Russians
recently reported the development of persistent hy-
pertension in monkeys subjected to conditioned
stresses.

Since the control of blood pressure has been
evolved with the development of animal species, one
would expect that this would be genetic in character.
Consequently, genetic variations might be expected
to lead to a range of normal blood pressure in a
large population that would deviate around a mean
in a dome-shaped curve, as Pickering has suggested
— a dome which would shift to higher levels of
blood pressure with age. And if any sort of elevation
of systemic blood pressure carries with it a detri-
mental effect on the arterial vasculature, which is a
function of the blood pressure level and the time
over which it operates, then one can see how such
genetically engendered high blood pressure would
lead in such persons to hypertensive vascular disease
more often than in those with a genetically lower
blood pressure level. This does not mean that this
is the only mechanism involved even on a genetic
basis. It simply means that the gearing of blood
pressure level over a wide range can be determined
by a genetic trait. Furthermore, this does not mean
that the distribution curves of pressure levels which
have been published prove that this is the only fac-
tor involved. It is quite possible that when a large
population subject to this factor is intermingled
with a smaller group subject to other factors, the
resulting distribution curve would be dome-shaped
with some degree of skewing, depending on the
relative size of the smaller group included.

This smaller group I am referring to would be
one having a disorder due to a maladjustment in
the regulation of blood pressure, however engen-
dered and regardless of the homeostatic blood
pressure level inherited genetically. Such a malad-
justment could also lead to hypertension and hyper-
tensive vascular disease. How this maladjustment in
regulation comes about in primary hypertension is
not yet established. I would like to consider in gen-
eral terms how this might develop.

People may show either a normal or excessive
blood pressure elevation in response to a given
stressful stimulus in the environment, the response
being related to a genetically inherited factor. Thus,
a stimulus, A, in one person would cause a tempo-
rary rise of blood pressure for a period which, both
as to height and duration, could be considered nor-
mal, while in another individual the same stimulus
would cause an excessive rise in blood pressure for

202

CALIFORNIA MEDICINE

an unusually protracted time. Now, if stimulus A
recurred frequently, or if the individual were sus-
ceptible to a wide variety of stimuli and these oc-
curred frequently, a labile hypertension would oc-
cur such as is seen early in primary hypertension.
This hypertensive response could be due to a
greater vasomotor sensitivity of the smooth muscle
of the blood vessels or an augmented cardiac output,
or both. The blood vessel response might also mean
a greater transport of electrolytes and water into the
arterial wall, increasing its turgidity and decreasing
its lumen. Whichever way it occurred, the decrease
in the bore of the arterioles would increase the
peripheral vascular resistance.

One must assume that continuation of these
hypertensive episodes can lead to anatomical
change in the arterioles so that their lumens remain
narrow and thus lead to the fixed hypertension seen
later. Add to this some new factor causing necrotiz-
ing arteriolitis in vital organs, and the stage for
accelerated hypertension is at hand. While these last
two stages have not been thoroughly explained, the
mechanism suggested seems logical even though it
is hypothetical.

Accelerated hypertension may start early in the
course of hypertension, sometimes even without a
period of benign hypertension. It would appear that
the occurrence of accelerated hypertension is de-
pendent upon the rate at which the blood pressure
rises to its unusually high level as well as upon the
height of the diastolic pressure reached. In secon-
dary hypertension the development of accelerated
hypertension is quite frequent when the initiating
cause is unilateral renal vascular occlusion. Hence
this possibility should be looked for in all cases of
accelerated hypertension. All these facts suggest that
the mechanism leading to accelerated hypertension
precedes the vascular damage seen in such cases in
the form of necrotizing arteriolitis. At least, the
mechanisms may be considered to cause the pressure
rise, the clinical deterioration and the vascular
change simultaneously. Later, of course, a vicious
cycle may be established which permits the hyper-
tension and the vascular changes to augment each
other.

What we must examine next and at greater length
is the mechanism by which the augmented response
in the blood vessels is produced. This could result
from any one or a combination of the following
mechanisms:

1. A greater reactivity of the vascular smooth
muscles, genetic or acquired, to the same efferent
nerve stimulus.

2. A greater vasoconstrictor bombardment of
blood vessels via the efferent nerves. This could be
caused by a different channelling of the reflex re-

sponse to the same stimulus from a sensor group as
a result either of central nervous system rein-
forcement over its pressor neurons or of a lessened
simultaneous involvement of central nervous system
depressor neurons, or both.

3. A greater response of the sensor to the same
stimulus acting upon it. One way by which this can
come about is through a change in the size of the
carotid sinus (and other mechanoreceptors) . It is
known that the carotid sinus sensor is a stretch re-
ceptor dependent on the distortion of the sinus wall.
If the size of the carotid sinus is increased, then a
given change in the blood pressure will produce a
greater stretch of its wall and thus a greater stimu-
lus of the carotid sinus mechanoreceptors. Greater
distensibility of the wall of the sinus independent of
its size could have a similar effect.

4. A greater release of pressor hormones or a di-
minished production of depressor hormones. This
could result either by the action of the autonomic
innervation of the endocrine glands which create the
hormones or by means of a more complex series of
steps which, in some instances, involve the volume
or composition of some of the body compartments.
A variant of this view is that there may be an alter-
ation in the rate of destruction of the released hor-
mones with respect to the rate of their liberation.
Thus, any decrease in the destruction rate of pressor
hormones with respect to the rate of their liberation
will have a pressor effect, and so will a decrease in
the destruction rate of depressor hormones with re-
spect to the rate of their liberation.

5. An increase in the volume of the arterial wall
with a reduction in the bore of the arteries resulting
from altered release of hormones which lead to an
increase in their water and salt content. Actual
measurements of arterial walls in established hyper-
tension has failed to indicate any change in their
water and salt content. This, however, does not pre-
clude the occurrence of such a change earlier in the
course of the disease, a change which could dis-
appear if the water and electrolyte change stimu-
lated connective tissue formation.

These are the most obvious mechanisms, but I
am sure others may be found which may include
among them the final mechanisms which will finally
explain hypertension. Whatever the answer may be,
it is obvious that the autonomic nervous system is
involved in all of them. This is borne out practically,
from the fact that the most effective therapy for
hypertension — secondary, primary and accelerated
— is by interference with the nervous system func-
tion, whether by the use of tranquilizers or ganglion
blockers, or by sympathectomy or the administra-
tion of agents that interfere with the action of nor-
epinephrine, the effector substance through which
the sympathetic system operates. These are the “non-

VOL. 97, NO. 4 • OCTOBER 1962

203

specific” actions which aid appropriate therapy
directed at the factor which is believed to be re-
sponsible for secondary hypertension. They are
employed alone when the factor causing the hyper-
tension cannot be remedied or the condition is con-
sidered to be primary hypertension.

The role of the kidney and electrolytes in hyper-
tension has been under discussion for several
decades. What is new is the possibility of a relation
between these factors and the adrenals. Recently, a
prominent role has been attributed to the adrenal
cortex and to aldosterone.

That the adrenals played a role in hypertension
was suggested long ago. As far hack as 1897, Neus-
ser indicated that adrenal cortical tumors are asso-
ciated with hypertension. This contrasts with the
hypotension in Addison’s disease. Even in the latter
disease it has been shown that hypertension can be
produced by prolonged administration of desoxy-
corticosterone acetate (doca), a temporary state
which slowly disappears after DOCA is withdrawn.
In the 1950’s aldosterone was identified, its func-
tions described and the disease of primary aldo-
steronism identified. Aldosterone was established as
the mineral corticoid of the adrenal cortex.

Goldblatt found, many years ago, that adrenalec-
tomy prevented hypertension in dogs in which the
renal artery was clamped. Other investigators found
that maintaining a good electrolyte balance in the
experimental animal prevented the hypotensive ef-
fect of adrenalectomy in hypertension of the Gold-
blatt type. In rats and chickens it has been shown
that doca, especially when given with large doses of
salt, can by itself lead to hypertension.

It is clear from experimental work that the cor-
tex contains two groups of hormones which affect
blood pressure. One group represents the glucocor-
ticoids, principally hydrocortisone, produced in the
zona fasciculata, and this group is subject to control
by the trophic pituitary hormone, ACTH. The other
group represents the mineral corticoids, principally
aldosterone, produced in the zona glomerulosa. Its
formation and secretion can occur even after hypo-
physectomy.

Glucocorticoids produce their hypertensive ef-
fects in the animal independent of salt. The hyper-
tension they produce is rapid in onset, mild in
degree and not of the accelerated form.

The mineral corticoids, aldosterone and doca, re-
quire salt in most species, and usually in large
amounts, to lead to experimental hypertension. The
hypertension is gradual in onset and is rather severe
and somewhat independent of the dose of the hor-
mone given. The hypertension that develops is of
the accelerated (malignant) form with necrotizing

arteriolitis. It is associated, furthermore, with a
hypokalemic alkalosis.

The possibility that aldosterone may be involved
in hypertension has led recently to intensive studies
concerning its regulation. To date, the following fac-
tors have been uncovered or suggested.

1. Sodium depletion stimulates aldosterone secre-
tion.

2. Potassium excess in the body fluids has a simi-
lar effect.

3. Davis and coworkers have found that in dogs
obstruction of the vena cava above the liver in-
creases aldosterone secretion. When ascites devel-
oped in the experimental animals, a substance was
found in the blood which these investigators con-
sider a trophic hormone specific for aldosterone —
aldosterone secreting hormone (ash). This last re-
quires confirmation.

4. Aldosterone excretion varies inversely with in-
travascular volume.

5. Aldosterone secretion appears to be inversely
proportional to renal artery pressure but not neces-
sarily to renal blood flow. This latter fact has re-
sulted in a spurt of work endeavoring to relate the
mechanism by which the kidney affects aldosterone
secretion. All of this tends to point to the juxtaglo-
merular (jg) cells.

The JG cells were observed in mice by Ruyter in
1925 and in man by Obermeier in 1927. The cells
are arranged concentrically around afferent renal
arterioles in the immediate vicinity of the glomeruli.
They contain granules which no other kidney cells
possess. Goormaghtigh in 1939 found that the gran-
ularity of the JG cells increases in renal ischemia
and assigned a secretory function to them, namely
the secretion of renin, which had long been known
as a product of the kidney. This has been confirmed
since then. Hartcroft demonstrated a parallelism
between the pressor activity of saline extracts of
the kidney and JG cell granularity. Dean and Masson
in 1951 found that injection of kidney extracts at
the time of high granularity of the JG cells causes hy-
pertrophy of the zona glomerulosa of the adrenal
cortex. Since then it has been established that the
degree of granularity of the JG cells and the role of
renal secretion of renin are affected in a fashion
parallel to the formation of aldosterone by the fac-
tors I enumerated earlier.

Sodium-deficient diets in rats, for example, cause
hyperplasia and hypergranulation of the JG cells at
the same time that the zona glomerulosa of the adre-
nal cortex is widened (up to eight fold) and aldoste-
rone secretion is augmented. Laragh found the effect
of potassium in the body fluids to be opposite to
that of sodium on the JG cells. Davis showed that
nephrectomy abolished the effect of vena cava occlu-
sion upon aldosterone secretion, and so it did upon

204

CALIFORNIA MEDICINE

the aldosterone secretion accompanying acute hem-
orrhage.

The granularity of the JG cells has been found by
many investigators, notably Schloss, Hartcroft and
Tobian, to depend inversely upon the pressure exist-
ing in the afferent arterioles of the glomeruli. The
mechanism, it seems, is that renin is released, which
in turn liberates angiotensin from a plasma globulin.
Hartcroft showed that the JG cell action can be af-
fected also by renal tissue pressure following ure-
teral ligation. Jg cell granulation is increased by
adrenalectomy and this increase can be reversed by
DOCA or aldosterone administration.

Thus, there is considerable evidence of a renal-
adrenal cortex interrelationship. Does this mean that
such a relationship involving renin-angiotensin-
aldosterone is responsible for human hypertension?
Genest has postulated that primary hypertension is
due to a persistent low-grade hyperaldosterone se-
cretion. But this is not proven. Several facts speak
against it. Aldosterone excretion is persistently ele-
vated in normal pregnancy in which no hypertension
is present, and the rate of excretion is of the same
order as in toxemia of pregnancy with hypertension.
Laragh has found that the aldosterone secretion
rate, measured by the isotope dilution method, is
not increased in primary hypertension. Taquini
noted that the renin content of the kidney and the
amount of renin liberated by the kidney was nor-
mal in hypertension. And this has been found to be
true for angiotensin as well. Examination of the
adrenal cortex in primary hypertension has failed to
demonstrate any change in the zona glomerulosa
although a change might be expected if aldosterone
secretion were altered.

In accelerated hypertension the situation is dif-
ferent. Here the JG cells are hyperactive and so is
the zona glomerulosa. There is evidence of increased
renin from the kidney, blood angiotensin content is
augmented and an increased aldosterone secretion
can be demonstrated. Even so, this does not prove
that these are causes of accelerated hypertension at

least as far as aldosterone is concerned. It is pos-
sible that the renin-angiotensin mechanism operates
in other ways not involving aldosterone.

Aldosterone secretion is elevated in many condi-
tions without hypertension, notably in the edema-
tous states associated with cirrhosis of the liver,
nephrosis and congestive heart failure. Even in pri-
mary aldosteronism there are a number of cases
with only minimal blood pressure elevation. In this
disease, the characteristics are hypernatremia, hypo-
potassemia and hypervolumia. Adrenalectomy has
been curative in primary aldosteronism but had
little effect on accelerated hypertension.

The fact that protracted administration of DOCA
and salt was found (by S. M. Friedman and asso-
ciates) to cause irreversible hypertension in ani-
mals— so-called metacorticoid hypertension — is not
surprising since any form of experimental hyper-
tension becomes permanent when protracted enough.
It cannot be used to prove that this form is the form
leading to primary hypertension, although it may
very well be one of several forms that may do so.
What bearing the recent work of Skelton on “adre-
nal-regeneration hypertension” has on the genesis
of primary hypertension is still undetermined. It is
a lead that warrants further investigation.

What does the future hold? It is hazardous to
speculate as to the direction of profitable future
studies but I will attempt it so as to round out the
presentation. It is my view that more profit will
ensue from the study of genetic factors and of the
integrative role of the nervous system than from
continued excessive concern with the adrenal-elec -
trolyte-renal mechanisms. It is in the former areas
that I predict new and exciting findings in the next
few years that will shed considerable light upon pri-
mary hypertension. I stress this here because new
knowledge about the pathogenesis of primary hy-
pertension will go far to improve the rational man-
agement of hypertensive vascular disease and will
lead ultimately to its prevention.

Michael Reese Hospital and Medical Center, Chicago 16.

YES on 22

VOL. 97

NO. 4 • OCTOBER 1962

205

Drug Therapy of Hypertension

ROBERT F. MARONDE, M.D., and L. JULIAN HAYWOOD, M.D., Los Angeles

In general, mortality in hypertension increases in
parallel with the blood pressure level.2,3,9’10 There-
fore, any procedure that results in a significant
decrease of the hypertension, without concomitant
complications that would offset the benefit derived
from this decrease in pressure, should lower the
death rate. Several investigators have reported that
this has been achieved by drug therapy.* A majority
of the patients dealt with in these reports had grade
III or IV Keith-Wagner hypertensive retinopathy.
In contrast, one hundred patients treated by thor-
acolumbar sympathectomy and 28 patients treated
with drug therapy were studied by the use of
matched controls and no decrease in mortality was
found.7,14 In the series dealing with thoracolumbar
sympathectomy, data were presented which made it
possible to compare the blood pressure levels of the
treated and control patients after a ten-year period.
Analysis of these data demonstrated that there was
no significant difference in average pressure between
the two groups. Data by which a similar comparison
could be made between the drug-treated group and
their controls were not presented.

A definite improvement in the degree of control
of the blood pressure as well as a decrease in the
side effects from antihypertensive drugs has, in our
opinion, occurred within the past two years. It is
the purpose of this report to demonstrate the de-
gree of control of the blood pressure of hypertensive
patients treated as outpatients.

METHODS

All patients who attended the hypertension clinic
of the Los Angeles County General Hospital in the
period of January to April 1960 were selected for
this study. In January 1962, patients who were lost
from the clinic during this period were traced. In
those patients who were still under observation, the
average supine and standing blood pressures for the
period of January to October 1961 were compared

From the Departments of Medicine of the University of Southern
California School of Medicine (Maronde), Loma Linda University
School of Medicine (Haywood), and the Los Angeles County General
Hospital, Los Angeles 33.

Presented as part of a Panel on New Approaches to Diagnosis and
Treatment of Hypertension at the 2nd General Meeting at the 91st
Annual Session of the California Medical Association, San Francisco,
April 15 to 18, 1962.

* References 1, 4, 6, 8, 15, 16, 17.

• Drug therapy can lower the blood pressure
levels of most hypertensive patients. The agents
now in use are usually better tolerated and more
effective than many of those available a few
years ago. it seems probable that there is a close
relationship between the elevated blood pressure
and the increased mortality rate of hypertensive
persons and that a significant lowering of this
pressure would result in a decrease in mortality.

In a pertinent study, the average pre-treat-
ment blood pressure of a group of 76 pa-
tients with moderate to severe hypertension was
198/119 mm. of mercury in the prone position
and 192/118 in the standing position. The pa-
tients were treated for a two-year period and
with treatment their average pressure over a
nine-month period was 164/99 mm. prone and
142/94 mm. standing.

Many drugs used for the treatment of high
blood pressure have more effect on the lowering
of this pressure when the patient is in the stand-
ing position. For this reason, the blood pressure,
while the patient is standing, should be used as
the guide for dosage of these drugs.

with control! pressures and with pressures recorded
during previous treatment.

Clinic visits were every two weeks, and three
observers measured the supine, sitting and standing
pressures. Each observer was responsible for an
entire visit. Therefore, one observer measured the
blood pressure of an individual patient every six
weeks. Comparison of the average pressure readings
of each observer with the readings of both the others
were made and no significant differences for the
same group of patients was found.13 During one
period in 1959 and again late in 1961 therapy was
stopped in over 40 patients for four to six weeks in
preparation for evaluation of new antihypertensive
agents. In both instances the average pressure of
the patients at the end of these periods did not
differ significantly from the control pressures that
had been obtained when they first entered the
clinic.11,13 This was true even though a satisfactory
response to other antihypertensive agents had been
noted for several months. Most of these patients
were included in the present study. Under the con-
ditions outlined, we concluded that it was valid to
compare the blood pressure levels during the treat-

fWhen the patient was first referred to the clinic, control blood
pressures were obtained by stopping medication for a period of
six to ten weelS, except for patients with active grade III or IV
Keith-Wagner hypertensive retinopathy, whose control pressures
were obtained from the hospital records.

206

CALIFORNIA MEDICINE

ment period with the control pressures even though
these control levels were obtained at a time that
preceded the treatment period.

Our sequence of treatment was: (1) reserpine or
a thiazide diuretic; (2) reserpine plus a thiazide
drug; (3) a thiazide plus guanethidine, and (4)
guanethidine and a thiazide plus reserpine. Supple-
mental potassium was usually given with the thia-
zides. The stages in this sequence were separated
by approximately six weeks and progression of one
schedule to the next was carried out if it was believed
that a satisfactory response had not taken place
(diastolic pressure of 100 mm. of mercury or be-
low). Guanethidine and a thiazide were given con-
comitantly because of the more pronounced effect on
the supine pressure as compared with the use of gua-
nethidine alone.12

RESULTS

A total of 137 patients were seen in the clinic dur-
ing the period January to April 1960. Twenty-eight
wrere new patients who were not subsequently treated
because they had only mild or labile or systolic
hypertension or because they were financially in-
eligible and were referred to private care. Two addi-
tional patients were referred to the hospital at the
time of their first visit because of malignant hyper-
tension. Of the remaining 107 patients, 24 were
treated but then were lost from the clinic during the
period January 1960 to January 1962. All were
traced and found to be alive. Twelve were under the
care of other physicians or were receiving no therapy.
Three of the 24 patients w'ere invalids as the result
of cerebral vascular thrombosis or hemorrhage. An-
other of the group of 24 was in hospital as the result
of a traffic accident and still another w7as in hospital
because of renal disease which antedated his first
clinic visit. Seven patients of the 24 had been referred
to the general medical clinic because of mild or
labile hypertension or because of inability to co-
operate with or understand the treatment program.
There were seven deaths in the 107 patients, three
from cerebral vascular disease, two from uremia,
one from carcinoma and one from cirrhosis of the
liver.

Seventy-six patients were treated and still were
under observation in the clinic in January 1962. The
average age of this group was 51 years. Sixty-three
were Negroes and 60 of the 76 were women. Forty-
one had electrocardiographic evidence of left ven-
tricular hypertrophy and 17 were taking digitalis.
There were eight with serum urea nitrogen above
25 mg. per 100 cc., and eight patients had grade
III or IV Keith-Wagner retinopathy. Eight new
patients were accepted for treatment between Janu-
ary and April 1961.

Compilations were made of the average blood
pressures of the 68 patients of this group of 76 who
were attending the clinic before January 1960. The
three-month period preceding January 1960 was
selected for this purpose. At that time 30 patients
were taking a ganglion-blocking agent plus reserpine
and/or a thiazide diuretic. The average pressure for
the group was 190/116 mm. of mercury supine and
178/102 standing. Thirty-eight patients received a
thiazide and usually reserpine but no blocking agent
during the three-month interval. Their average pres-
sures were 172/108 supine and 165/105 standing.
It should be noted that many in this group had
previously been given ganglion-blocking agents but
were unable to tolerate them because of side effects.

In the period January to October 1961, 12 of the
76 patients received only a thiazide diuretic. Their
average pressures were 142/92 mm. supine and
136/93 standing as compared with control levels of
180/111 supine and 177/111 standing. Twenty-four
patients were treated with a thiazide and reserpine.
The average treatment pressures were 157/93 supine
and 134/90 standing while the respective control
pressures were 194/116 and 188/112. Two patients
in this treatment group were unable to tolerate any
other antihypertensive agents because of side effects,
and their blood pressure control was not adequate.
Twenty-one patients were treated with guanethidine
and a thiazide. Their average pressures during treat-
ment were 173/102 and 147/94, supine and stand-
ing, and their control blood pressures were 204/122
supine and 197/122 standing.

A group of nine more severely ill patients, three
of whom had serum urea nitrogen above 30 mg.
per 100 cc. and another two with grade III or IV
Keith-Wagner retinopathy, were treated with gua-
nethidine and a thiazide plus reserpine. Their con-
trol pressures were 208/126 supine and 203/130
standing. The comparable averages during treat-
ment were 184/113 and 160/104. The fact that
three antihypertensive agents were used in the
treatment of the patients of this group indicates a
resistance to therapy (see foregoing description of
methods). Two of this group of nine patients were
unable to tolerate effective doses of guanethidine
because of the side effects.

Four patients were treated with reserpine only.
Three of them had previously required a blocking
agent for a prolonged period to control their blood
pressure. It is not frequent, in our experience, that
dosages of antihypertensive agents may be greatly
reduced once blood pressure control has occurred.

Six patients who were treated with mecamylamine
or hydralazine complete the total of 76 patients. The
four who received mecamylamine had had adequate
control of pressure before January 1960 and their
therapy was not changed. The two patients taking

VOL. 97. NO. 4 • OCTOBER 1962

207

hydralazine could not tolerate guanethidine or gan-
glion-blocking agents, one because of side effects,
the other because of increased elevation of serum
urea nitrogen. Neither of these latter patients had a
significant change in pressure levels.

DISCUSSION

The patients presented here are not a representative
sample of the hypertensive population. This is evi-
dent by the preponderance of Negroes, the high
average blood pressures and the frequency of the
electrocardiographic finding of left ventricular hy-
pertrophy. Mortality statistics pertaining to a group
of this type are not available but undoubtedly the
mortality rate for them would exceed that of the
hypertensive population as a whole.

Eight patients of this group had a disappearance
of their electrocardiographic abnormalities. No
deaths resulted from cardiac decompensation. This
is of interest since this has been the cause of ap-
proximately 60 per cent of hypertensive deaths.5
This probable decrease in the incidence of death
from hypertensive heart disease is in accord with
the report of Sokolow and Perloff.17 Whether or not
drug therapy has influenced the incidence of cerebral
vascular lesions or nephrosclerosis is not apparent
from the present study. Of the three patients who
had non-fatal cerebral vascular episodes all had a
poor blood pressure response with antihypertensive
agents. However, in two of the three fatal cases of
cerebral vascular lesions the blood pressure response
to drug therapy had been considered adequate. The
11 patients with serum urea nitrogen levels above 25
mg. per 100 cc. all had evidence of renal disease at
the time of their first clinic visit. No real change in
these levels occurred in the eight surviving patients
during this period of observation. The three patients
who died of renal disease came to the clinic with
serum urea nitrogen greater than 50 mg. per 100 cc.

Our treatment schedule at present has been
slightly modified. Therapy is started with a thiazide
and not reserpine. Using the double-blind technique,
we were able to demonstrate a slight effect on only
the standing diastolic pressure but no effect on the
supine pressure or standing systolic pressure when
0.5 mg. of reserpine per day was given over a 12-
week period.13 Other investigators using a similar
technique had previously demonstrated that no sta-
tistically significant blood pressure change resulted
from reserpine by mouth when it was the sole thera-
peutic agent.18

CONCLUSIONS

Drug therapy can lower the blood pressure levels
of hypertensive patients in the majority of cases. The
agents now in use are usually better tolerated and
more effective than many of those available a few
years ago. It would be difficult to believe that a close
relationship between the elevated blood pressure and
the increased mortality rate of hypertensives did not
exist and that a significant lowering of this pressure
would not result in a decrease in this mortality rate.

U.S.C. School of Medicine, 2025 Zonal Ave., Los Angeles 33
( Maronde) .

REFERENCES

1. A symposium on hypertensive drugs, Brit. Med. J.,
1:915, 1956.

2. Bechgaard, Poul: Arterial hypertension, Acta Med.
Scand. Suppl. 172, 1946.

3. Bolt, W., Bell, M., and Haines, J.: New York Life In-
surance Co., Assoc, of Med. Directors of America, 41:61,
1957.

4. Burnett, C. F. Jr., and Evans, J. A.: Drug therapy in
hypertension with hemorrhagic hypertensive retinitis,
N.E.J.M., 253:395, 1955.

5. Chasis, H., and Golding, W.: Hypertension and hyper-
tensive disease, The Commonwealth Fund, 1944.

6. Dustan, H. D., Schneckloth, R. E., Corcoran, A. C., and
Page, I. H. : The effectiveness of long term treatment of
malignant hypertension. Circulation, 18:644, 1958.

7. Evelyn, K. A., Singh, M. M., Chapman, W. R., Perera,
G. A., and Thaler H.: Effect of thoracolumbar sympathec-
tomy on the clinical course of primary (essential) hyper-
tension, Amer. J. Med., 28:188, 1960.

8. Freis, E. D., and Wilson, I. M.: Results of prolonged
treatment with pentolinium tartrate, Circulation, 13:856,
1956.

9. Gubner, R. S.: Hypertension, Recent Advances, Lea &
Febiger, 1961.

10. Lyle, A. M.: A pilot study of hypertension, Transac-
tions of the Society of Actuaries, No. 4, 1954.

11. Maronde, R., Barbour, B., and Haywood, L. J.: Clin-
ical evaluation of guanethidine, Ann. N. Y. Acad. Sci. Vol.
88, 990, 1960.

12. Maronde, R. F., Haywood, L. J., and Barbour, B. :
Comparison of guanethidine and guanethidine plus a thia-
zide diuretic, Am. J. Med. Sci., 242:228, No. 2, 1961.

13. Maronde, R. F., Haywood, L. J., Feinstein, D., and
Sobel, C.: Evaluation of Pargyline and Pargyline plus reser-
pine as antihypertensive agents. To be published.

14. Perera, G. A.: Antihypertensive drugs versus sympto-
matic treatment in primary hypertension, J.A.M.A., 173:11,
1960.

15. Perry, H. M. Jr., and Schroeder, H. A.: The effect of
treatment on mortality rates in severe hypertension, Arch.
Int. Med., 102:418, 1958.

16. Sears, H. T. H., Snow, P. J. D., and Houston, I. B. :
Treatment of hypertension with pentolinium and mecamyla-
mine, Brit. Med. J., 1:462, 1959.

17. Sokolow, M., and Perloff, D.: Five year survival of
consecutive patients with malignant hypertension treated
with antihypertensive agents. Am. J. Cardiol., 6:858, 1960.

18. Veterans Administration cooperative study on anti-
hypertensive agents, Arch. Int. Med., 106:81, 1960.

YES on 22

208

CALIFORNIA MEDICINE

Initial Care of Acute Back Injuries

J. MINTON MEHERIN, M.D., San Francisco

In dealing with acute injuries to the back, the first
examination should be made with the patient com-
pletely undressed. If pain is so severe that he cannot
be undressed at once, he should be put in hos-
pital and as complete an examination as possible
should be made with the patient recumbent. Even
with this disadvantage an evaluation of muscle
spasm, areas of localized tenderness, leg signs, re-
flexes and sensation can be made. No back exami-
nation is complete without a physical examination,
which should include rectal and pelvic examination.
The survey of the lowrer extremities should take note
of the arterial pulsations and the movements of the
feet. The habitual use of a mimeographed sheet for
routine examination of the back and extremities ex-
pedites making the necessary notations and becomes
an important initial part of the patient’s permanent
record. The examination should at least include the

following:

1. Posture

2. Gait

3. Level shoulders

4. Level iliac crests

5. Pain

6. Tenderness

7. Muscle spasm

8. Neck flexion

9. Cough

10. Forward flexion

a. Standing

b. Sitting

11. Extension

12. Lateral flexion

13. Rotation

14. Straight leg raising

15. Lasegue sign

16. Knee jerks

17. Ankle jerks

18. Babinski sign

19. Muscle weakness

20. Sensation

21. Leg length

22. Circumference :

a. Thigh

b. Calf

23. Knees

24. Ankles

25. Feet

26. Pedal pulses

It is extremely important to determine the exact
mechanism of injury and the history of previous
back affections at the first visit. These facts are
ideally ascertained from the patient during the
course of the examination. The examiner should
learn the stress that was involved in producing the
pain. If the injury was incurred in lifting a weight,
he should know the approximate weight of the lift,
its duration, the position of the patient (awkward or
natural), the shape and size of the object lifted. He
should get as clear a picture as possible of the forces
that were involved during the stress and the planes
in which they were involved. He should find out

Presented as part of a Symposium on The Back before a joint
meeting of the Sections on General Practice and Physical Medicine
and Industrial Medicine and Surgery at the 91st Annual Session of
the California Medical Association, San Francisco, April 15 to 18,
1962.

• The mechanism of injury to the back should
be obtained with the utmost accuracy and set
down in the history as a separate paragraph un-
der that heading. This is usually best obtained
by questioning and requestioning the patient
during the course of the examination. A history
of any previous back affections should also he
obtained at the first visit.

The detailed examination of the back is not
complete without a general physical examina-
tion.

X-ray studies should be done immediately in
all cases in which the injury has been caused by
direct violence or forceful indirect violence (as
in “jackknife” injury).

Terms such as “disc disease,” “ruptured in-
tervertebral disc” and various others that convey
a similar meaning should not be used as the ini-
tial diagnosis and should be withheld until such
a diagnosis is definitely established.

The plan of treatment may include a period
in hospital or of rest at home, or it may be car-
ried out with the patient ambulatory. Corsets
and braces should be prescribed only when they
are to serve a definite function and the same
can be said of physiotherapy.

whether the task which brought on the symptoms
was routine or extraordinary and whether the pa-
tient was accustomed to the type of work or whether
it was unusual.

Part of the immediate and later prognosis depends
on these facts, just as the initial period of uncon-
sciousness is important in judging the severity of a
head injury. This information is often of inesti-
mable value in later separating the real from the
unreal symptoms. It should be included in any re-
port under a caption “Mechanism of Injury.”

The details of previous back injuries or affections
will only be gleaned by persistent probing on the
part of the examiner. Serving as reminders to for-
getful patients are the questions: “Have you ever
been in a hospital?” . . . “How many times?” . . .
“Reason?” . . .

X-ray films should be taken immediately in all
cases in which the injury has been caused by direct
violence or by forceful indirect violence as in “jack-
knife” injury. It is advisable in such cases that the
attending physician be present in the x-ray depart-
ment to assist the technicians in positioning the
patient. It should be his aim to obtain the maximum
information with the least disturbance of the patient.

VOL. 97, NO. 4 • OCTOBER 1962

209

In other cases of acutely painful back injuries, x-ray
studies may be deferred until severe pain has sub-
sided. Routine laboratory work should include a
determination of the blood sedimentation rate and
often uric acid determination.

DIAGNOSIS

Thei'e is no term which satisfactorily describes
the lower back syndrome. “Sprain, lower back” has
become a universal term which, although it means
many different things to many different people, is
perhaps the best general epithet for the condition.
“Disc disease,” “ruptured intervertebral disc” and
the various other terms which convey a similar
meaning should not be used as the initial diagnosis
and should be withheld until such a diagnosis is
definitely established. If there are clinical signs
of nerve involvement an acceptable diagnosis is
“Sprain, lower back with nerve root involvement.”
The diagnosis should also include the evidence of
preexisting disease. For example: “Sprain, lower
hack — hypertrophic osteoarthritis preexistent.”

TREATMENT

After completion of the initial survey the exam-
iner must then decide upon a plan of treatment. In
general there are three choices — to put the patient
in hospital, to prescribe rest at home or to treat him
while ambulatory.

In Hospital

If the back is acutely painful with severe muscle
spasm and a list, the patient does best with immedi-
ate admittance to hospital, bed rest in a proper con-
tour position and use of analgesics and moderate
heat. When the acute phase has subsided the appli-
cation of bilateral leg or pelvic traction helps to
keep the patient at rest in bed. Ordinarily traction
is kept in place for ten to twelve days, but for a
shorter time if the patient can perform all bed exer-
cises without pain. Results of the use of muscle re-
laxant drugs have at best been questionable in the
cases in which I have used them, although in a few
cases in which they were given intravenously the re-
sponse was dramatic. Sometimes, however, relapse
quickly followed.

Rest at Home

Rest at home should be allowed only under the
most ideal conditions. For the most part it is more
or less a delusion on the part of the patient and the
physician.

Ambulatory

Ambulatory treatment is reserved for cases of
minor affections in which more definitive treatment
seems not to be warranted.

Persistent painful trigger points should be in-
jected with procaine and hydrocortone.

Obvious foot conditions which could interfere
with proper weight bearing should be corrected.

If the patient is to be given physiotherapy a defi-
nite course of treatments should be laid out, with an
estimate made of expected results and a time limit
set for accomplishing them. However, there should
be no limit set on the duration of each treatment
period or on the time that the patient will he con-
fined to the physiotherapy department. The usual
half-hour period allotted for physiotherapy treat-
ments has no logical basis. The lazy and uncoopera-
tive patient may require sessions two or three or
four times longer than his opposite. The uncoopera-
tive patient should be taught that if he protests
fatigue, the exercises will be interrupted for rest
periods, not ended: the scheduled exercises will be
resumed after a rest, and carried on until com-
pleted, no matter how long it takes.

If the results from physiotherapy that were esti-
mated at the outset are not accomplished after the
prescribed set course, then the treatment should be
reviewed by the physician and the physiotherapist.

A physiotherapy regimen not augmented by a
definite exercise schedule that the patient must fol-
low at home is, to say the least, incomplete. The pa-
tient should be carefully instructed in the regimen
that he is to follow at home and he should be re-
peatedly quizzed as to what he is doing and how he
is doing it so that one may he sure that the patient
understands the importance of the therapy.

An intelligent patient will find the pamphlet “ Care
of the Back”1 helpful. The patient’s complete co-
operation is mandatory; without it, physiotherapy
cannot be effective. If the patient’s condition is not
somewhat improved after three to five consecutive
physiotherapy treatments, this method probably will
not be effective and should be stopped.

The use of corsets and braces should be decided
upon during the course of physiotherapy. The pa-
tient should he weaned from them as soon as they
have served their purpose and should not be allowed
to become dependent upon them unless they are
needed.

Consultation is desirable within the first two
weeks in cases in which the patients are not showing
satisfactory progress and in those in which the ob-
jective findings cannot he coordinated consistently
with the complaints. The attending physician should
decide what he hopes to gain from consultation and
select the consultant. When the objective findings
and the complaints do not coincide, consultation
should be called if only to substantiate the attend-
ing physician’s findings.

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PROGNOSIS

Prognosis as to time of recovery in this injury
is indefinite. It is fair to state that usually if hack
pain ostensibly resulting from relatively minor
stresses and strains continues for a long time, some
other underlying pathologic condition is a proba-
bility. Almost every case is complicated by multiple
divergent factors in addition to the obvious psycho-
somatic status. To indicate just a few:

What is the employer-employee relationship?

Will the employer permit the patient to return to
modified work for two to three weeks until he re-
gains his strength and confidence?

Is he a long-time, useful, trusted employee or was
he new to the job when he was injured?

Is there a wide spread between the patient’s work-
ing earnings and his disability payments?

What are the patient’s financial needs?

Has he approached retirement age?

These and many other issues surround almost
every prognosis.

760 Market Street, San Francisco 2.

REFERENCE

1. Ishmael, W. K., anti Shorbe, H. B.: Care of the Back,
J. B. Lippincott Company. Reprinted June 1961.

YES on 22

VOL. 97, NO. 4 • OCTOBER 1962

211

Anxiety and Worry as Aspects of Normal Behavior

JUDD MARMOR, M.D., Beverly Hills

One of the commonest misconceptions about hu-
man behavior is that anxiety and worry are al-
ways abnormal. “How to Get Rid of Anxiety,” or
“How to Stop Worrying” are favorite topics in the
countless self-help books, magazine articles and
newspaper columns which constantly exhort the
American public on the means of achieving a better
life. It is an extraordinary fact that even the psychi-
atric and psychological professions, which should
know better, have done almost nothing to dispel this
misconception and, indeed, in many instances have
contributed to its perpetuation.

The purpose of this communication is to review
briefly a few ideas about the nature of anxiety and
worry, and to indicate that within certain limits
these phenomena are significant and essential as-
pects of normal human behavior. Let us begin with
some basic definitions.

One of the fundamental principles which underlie
all human activity is the need of the organism to
maintain homeostasis with regard to both its inter-
nal and its external environment. When homeostatic
control is threatened, the organism is mobilized into
adaptive efforts at regaining control. Anxiety refers
to the signal of present or future danger with which
the ego seeks to mobilize all the organism’s re-
sources in the interests of defense, self-preservation
or the restoration of homeostasis.

The differentiation between anxiety and fear has
been a source of frequent discussion in the psychi-
atric literature, and there is no uniform agreement
about it. In general, the term fear is used to refer
to reactions to known, tangible and objective dan-
gers, while the term anxiety is reserved for reac-
tions to unknown, intangible and subjective ones.
Fear, moreover, most often refers to present dan-
gers, while anxiety is more apt to refer to antici-
pated or future ones. Actually, a sharp line of dis-
tinction between them is not always possible even
on the basis of the above criteria. Physiologically,
moreover, there is no difference between fear and
anxiety. In both, the organism mobilizes the same
autonomic and humoral resources to facilitate either
“fight or flight.”

Although laymen often use the terms anxiety and

Presented at the Symposium on "Management of Anxiety for the
General Practitioner," held February 24 and 25, 1962, at the Los
Angeles County Hospital, Los Angeles 33.

Clinical Professor of Psychiatry, UCLA Medical School, Los An-
geles 24.

Submitted June 27, 1962.

• Anxiety and worry are not necessarily psycho-
pathological reactions. Anxiety is a basic physio-
logical and affective response to the perception
of danger. Worry is an effort to deal with the
perceived threat at an intellectual level. Realistic
anxiety and worry, based on objective and real-
istic dangers, should be distinguished from neu-
rotic anxieties and worries.

Within certain limits realistic anxiety and
worry are useful adaptive mechanisms which en-
able a person to cope more effectively with an-
ticipated dangers. Excessive anxiety and worry,
however, or the absence of these reactions in
circumstances where they would be appropriate,
both tend to lead to maladaptive responses.
These considerations have certain useful impli-
cations in medicine, notably in the preparation
of patients for surgical operation.

worry interchangeably, in actuality they represent
quite different orders of responses to danger. Anxi-
ety is a primitive, basic, physiological and affective
response to the perception of danger. Worry, on the
other hand, can he characterized as a kind of appre-
hensive thought which is mobilized by anxiety, and
which represents an effort on the part of the organ-
ism to cope with the anticipated danger.2 Anxiety
is an emotional signal, an alerting mechanism.
Worry is a form of mental activity, an effort at
problem-solving. It must be emphasized, however,
that although worry differs in nature from anxiety,
it never exists without anxiety. The mental work of
worry is always triggered by and associated with
underlying feelings of anxiety. It is undoubtedly for
this reason that they are so often confused with one
another.

Let us now return to our topic of anxiety and
worry as aspects of normal human behavior.

Anxiety can be conceived of as being at the end
of a long evolutionary chain which goes all the way
back to protoplasmic irritability and animal vigi-
lance. As a psychological reaction it is comparable
to its physiological analogue, the sensation of pain.
Both are signals to the organism that something is
threatening its integrity, and both are essential alert-
ing mechanisms which enable the organism to make
the proper adaptive responses. Just as an individual
lacking the capacity to feel pain would be seriously
handicapped, so also would be an individual who
was incapable of reacting with anxiety. On the
other hand, if too much pain is present, it can actu-
ally interfere with the organism’s ability to deal

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CALIFORNIA MEDICINE

with the noxious stimuli. Thus, what normally
serves as an essential protective device can, if it
becomes excessive, act as a destructive influence or
a kind of disease in itself. The same is true of anxi-
ety. In mild or moderate form it acts as a construc-
tive force, spurring the ego on to make adaptive
attempts at mastering the actual or potential threat
to its safety. Thus, moderate anxiety has been shown
to facilitate learning. If the ego’s efforts at mastery
fail, however, then the anxiety increases to a point
where it in itself becomes a handicap to the ego’s
adaptive efforts. In extreme form, anxiety may cause
total disorganization or paralysis of ego activity.
We see examples of this in panic reactions, in agi-
tated depressions, and in catatonic excitements. Ex-
amples of the pathological absence of anxiety can
be seen in “la belle indifference” of the classical
hysteric, in the flattened emotions of the hebephre-
nic, and in the apathetic reactions of certain psy-
chotic depressives. We also see it in everyday life
in the reaction of denial, in which a person re-
presses or denies the existence of a threat — a kind
of psychological equivalent of the ostrich’s sup-
posed act of burying its head in the sand when
threatened. We shall have more to say about this
mechanism later on.

Even moderate anxiety can be pathological if its
real sources are repressed and unconscious. Such
anxiety appears in the form of so-called “free-float-
ing anxiety” or “nameless dread” with which the
ego is powerless to cope since it is unable to iden-
tify the repressed threat which is provoking the
anxiety. Similarly, when the anxiety is displaced
from its real origins to some substitutive object, as
in the phobias, the ego is also unable to effectively
cope with the repressed threat. In normal anxiety,
however, the threat, whether immediate or antici-
pated. is realistic and conscious, and the ego is mo-
bilized into efforts at preparing for it or coping
with it.

REALISTIC WORRY

Worry represents such a coping effort at the in-
tellectual level. Realistic worry is based on realistic
anxiety — that is, it is related to realistic danger, im-
mediate or anticipated. Although at times it may at
first glance seem to be related to a past traumatic
experience, closer analysis will usually indicate that
what the worried ego is struggling with are the pres-
ent or future consequences of the experience. Thus
a student who is worrying about having failed an
important examination is really concerned with
what is going to happen to him as a consequence of
the failure.

Successful worry leads either to action designed
to cope with or eliminate the threat which has pro-
voked the underlying anxiety, or else to a new

homeostatic equilibrium in which the individual
intellectually adapts to the threat and is able to live
without being distressed by it any longer. An exam-
ple of the first reaction would be the student whose
worry over his poor showing in an examination
spurs him into harder and more effective study to
compensate for his poor grade. An example of the
second reaction would be the student who finally
makes his peace with the fact that he is not going to
be an outstanding scholar and sets his sights more
realistically.

NORMAL ANXIETY USEFUL IN MEDICINE

Normal anxiety and worry have special signifi-
cance in medicine and surgery. Preventive medicine
rests on a foundation of realistic anxiety and antici-
patory concern. Without it, people would be less
likely to undergo prophylactic inoculations and
periodic health examinations, or to watch their diets,
or to give up any immediate pleasures in the interest
of a long-range health program.

In surgery the problems of realistic anxiety and
worry have a particular importance. Internists and
surgeons have long been aware that the mental atti-
tude of a patient about to undergo a serious opera-
tion seems to have a significant effect not only on
the postoperative course but even upon his ability
to tolerate the surgical procedure itself. This has led
to efforts at preoperative “psychic buffering,” par-
ticularly in the form of the routine administration
of barbiturates on the night before operation. On
the purely psychological level, surgeons generally
try to cope with the patient’s anxieties by adminis-
tering liberal doses of reassurance, or by minimizing
the seriousness of the imminent procedure: “Don’t
worry about a thing — just leave the worrying to
me,” or “It’s nothing at all — you’ll be up and walk-
ing around in three or four days.”

The underlying assumption in these approaches
is that it is bad for the patient to be worrying about
the anticipated operation. On the other hand, if
what I indicated in earlier paragraphs has any
validity, the conclusion seems justified that it would
be just as unhealthy for a patient not to worry at
all about a serious surgical procedure as it would
be for him to worry too much. A number of studies
have been done in recent years which indicate pre-
cisely this. One of these studies, by Janis of Yale
University,1 is particularly pertinent. Janis studied
a group of 23 patients before and after their under-
going major surgical operation and found that they
fell into three broad groupings, according to their
anxiety levels:

1. Patients with extremely high preoperative anx-
iety, who were constantly worried and agitated,
could not sleep and could not be reassured. Their

VOL. 97. NO. 4 •

OCTOBER 1962

213

excessive fears of body damage were linked with
many clinical signs of chronic neurotic disturb-
ances which could be traced back to early life ex-
perience. Patients in this group were more likely
than the others to show excessive anxiety postopera-
tively also.

2. Patients with moderate anticipatory anxiety,
who were occasionally tense or agitated and wor-
ried about specific features of the operative pro-
cedure or anesthesia, but who tended to be relieved
when given authoritative reassurance. Patients in
this group were significantly less likely than the
others to have postoperative emotional disturbances.

3. Patients with little or no anticipatory anxiety,
who were constantly cheerful and optimistic, denied
any concern or worry, slept well and showed no ob-
servable evidences of tension. Patients in this group
were more likely than the others to display post-
operative reactions of intense resentment and irri-
tability.

CONSTRUCTIVE WORRY

These and similar observations confirm the propo-
sition that a moderate amount of anxiety and worry
over an anticipated real trauma is normal and
enables a person more effectively to cope psycho-
logically with the traumatic experience. This is
important in helping us to know what kind of psy-
chological communications we can make to patients
to help them in their coping efforts — to help them
worry constructively, so to speak. Thus it is not help-
ful to a patient to be told he is not going to experi-
ence any pain or other difficulties if in fact he is. It
is far better to give him a reasonable idea of what he
can expect as well as what will he done to help him.
The anticipatory anxiety which he thus experiences
enables him to be better prepared psychologically to
cope with the difficulties when they do occur. On the
other hand, if an individual fails to do this “work
of worry” in response to an anticipated danger, and
instead falls back on the mechanism of denial, this
defense will tend to break down when the danger
or suffering actually occurs, and intense feelings of
helplessness, panic or rage then tend to ensue.3

This is one of the reasons, incidentally, why un-
expected traumas are much more apt to cause emo-
tional disturbances than are expected ones. In the
former there is no opportunity for realistic antici-
patory anxiety and worry on the part of the ego
which would enable it to prepare its defenses for
the danger when it arrives.

In conclusion, a question may properly be asked
as to the practical significance of recognizing that
realistic anxiety and worry are aspects of normal,
indeed healthy, human behavior. My reply would
be that such recognition not only may lead to the
elimination of unwarranted feelings of guilt and

self-depreciation in people, but also to more thera-
peutic psychological attitudes and communications
on the part of physicians or other authority figures
toward people with such anxiety. We had a dra-
matic verification of this on a large scale in the
experiences of the past two World Wars. The recog-
nition and teaching that fear is a normal human re-
action under conditions of danger was of enormous
help in maintaining the morale of many soldiers in
World War II, who were thus relieved of the enor-
mous additional burden of guilt and social condem-
nation which their predecessors in World War I
experienced when they felt afraid. By the same
token, I believe that the misconception that worry
of any kind is abnormal is responsible for wide-
spread tension in many intrapersonal and inter-
personal situations. Many people are apparently
unaware of the fact that to be unworried in the face
of a threatening reality situation may be a sign of
mental disorder rather than of mental health.

This also has implications in relationship to the
prescription of tranquillizing drugs. Without in any
way minimizing the invaluable contribution which
these drugs have made in the management of severe
mental illness, it is important to recognize that their
use is logically indicated only where there is exces-
sive anxiety, not realistic anxiety. To block out a
patient’s realistic anxiety would be to deprive him
of an essential part of his adaptive apparatus.
Where real problems exist, the task of the physician,
whenever possible, is to help the patient face these
problems objectively and cope with them construc-
tively. The difference between mental health and
neurosis lies not in the absence of problems but in
the ego resources which a person is able to bring to
bear on the problems which always exist; not in
the absence of anxiety, worry or grief, but in
whether or not these reactions have a realistic basis
and whether or not they ultimately lead to construc-
tive coping activity on the part of the human or-
ganism.

HEALTH AND HAPPINESS NOT SYNONYMOUS

All too often psychiatric patients have the illusion
that mental health and happiness are synonymous,
and that when they are “cured” they will “live hap-
pily ever after.” Obviously even the most successful
psychotherapeutic procedure cannot guarantee hap-
piness for anyone. The world in which we live
presents us with a continuous succession of real
problems and difficulties. Even if our personal lives
are momentarily free from stress, the world at large
never is. We would be less than healthy if we did
not all share some concern about, for example, the
current state of our planet.

One of the challenges which confront modern
man, probably more than any of his forebears, is

214

CALIFORNIA MEDICINE

the necessity of living with continuous uncertainty
and tension. Shorn of his belief in his immortality,
shaken in his faith in a personal and protective God,
faced with the prospect of living on the brink of
nuclear extinction for an indefinite time to come,
modern man cannot but live in a state of constant
“existential” anxiety. This is part of the price we
pay for being human, but it is a price worth paying
for the freedom that comes with self-awareness.

9950 Santa Monica Boulevard. Beverly Hills.

REFERENCES

1. Janis, I. L.: Emotional Inoculation: Theory and Re-
search on Effects of Preparatory Communications, in Psy-
choanalysis and the Social Sciences, International Univer-
sities Press, Inc., New York, 1958, pp. 119-1954.

2. Marmor, J.: The Psychodynamics of Realistic Worry,
in Psychoanalysis and the Social Sciences, International
Universities Press, Inc., New York, 1958, pp. 155-162.

3. Marmor, J.: Psychological Preparation of Patients for
Major Surgery, Rounds of the Teaching Staff, Journal of
the Wadsworth General Hospital, Vol. 4, No. 7, March
1961, pp. 303-308.

YES on 22

VOL. 97. NO. 4

OCTOBER 1962

215

Repair of Vesico-Vaginal Fistula

EDWARD C. HILL, M.D., San Francisco

The foundation of gynecologic practice, as it is
known today, was laid on the cornerstone of a tech-
nique for the almost uniformly successful repair of
vesico-vaginal fistulas. Over a hundred years ago,
Sims9 reported an 83 per cent cure rate in a series
of 261 cases. In Sims’ day, more than 85 per cent
of fistulas were obstetrical in origin — most of them
resulting from pressure necrosis of the bladder wall
secondary to impacted fetal heads in bony dystocia
problems. Few of them were due to traumatic de-
livery methods. Today, with early recognition of
cephalopelvic disproportion and the increasing use
of cesarean section, the incidence of vesico-vaginal
fistulas of obstetrical origin has been sharply re-
duced.

It is well recognized that the most common cause
of vesico-vaginal fistulas today is gynecological sur-
gical operation.1,3,6 That the impetus for the devel-
opment of modern pelvic operations should have
been a condition which is now frequently the result
of such operations is an unfortunate medical para-
dox. Because of this, it is considered important to:
(1) note the incidence of vesico-vaginal fistulas
in a modern hospital setting; (2) determine the
causes; (3) suggest methods for avoiding bladder
injury at the time of operation; and (4) review the
results that have been obtained with various surgical
techniques for the repair of these fistulas.

MATERIALS AND METHODS

This study represents a review of the case histo-
ries of 113 patients admitted to or discharged from
the University of California Hospital, with a diag-
nosis of vesico-vaginal fistulas, from 1932 through
1959. Many of these patients were referred from
areas throughout Northern California, although ap-
proximately 15 per cent of the fistulas occurred as
a result of procedures carried out at U. C. Hospital,
primarily in the treatment of pelvic malignant dis-
ease.

The causes of these fistulas were analyzed and the
methods of management were reviewed. Particular
attention was paid to those patients in whom surgi-

From the Department of Obstetrics and Gynecology, University of
California School of Medicine, San Francisco 22.

Presented before the Section on Obstetrics and Gynecology at the
91st Annual Session of the California Medical Association, San Fran-
cisco, April 15 to 18, 1962.

• One hundred and thirteen patients with
vesico-vaginal fistula were seen at the University
of California Hospital from 1932 through 1959.
The most common cause of fistula was trauma
associated with pelvic operation, and the opera-
tion most often involved was total abdominal
hysterectomy. Malignant disease of the pelvic
organs was the second most common cause, while
radiation therapy and obstetrical causes were
next in the order of frequency.

Three fistulas healed spontaneously. Twelve
bladder by-pass operations were done and 54
repairs were carried out in 46 patients. Thirty-
eight patients (82.6 per cent) were cured after
one or more repair operations. A variety of op-
erative approaches were used, selected in ac-
cordance with the needs of the individual case.
Bladder distention postoperatively, due to a
plugged catheter, was held responsible for fail-
ure of the repair in three cases, and this com-
plication was considered preventable.

Close attention to surgical technique, the rec-
ognition of bladder injury, and proper repair at
the time of operation are prime factors in the
prevention of vesico-vaginal fistula.

cal repair of the fistula was carried out, and an
attempt was made to determine the factors respon-
sible for failure of repair.

FINDINGS

Etiology. Of the 113 cases of vesico-vaginal fis-
tulas studied, 51 (46 per cent) were the result of
pelvic operation and 31 of these were associated
with total abdominal hysterectomy. The second most
common operation associated with fistula was radi-
cal hysterectomy for malignant disease, and in the
remainder of cases the lesions were related to other
procedures in the pelvis, both abdominal and vagi-
nal (Table 1).

Malignant disease involving the genito-urinary
tract accounted for 38 ( 34 per cent ) of the fistulas,
while radiation therapy for malignant disease was
held responsible in 11 (10 per cent). There were
11 patients (10 per cent) with fistulas of obstetrical
origin, and in ten of them the lesion was associated
with difficult forceps delivery. In only one did fis-
tula occur following delivery by cesarean section.

Management. Three of the fistulas healed spon-
taneously, one of them being an obstetrical fistula,

216

CALIFORNIA MEDICINE

TABLE 1. — Causes of Vesico-Vaginal Fistulas, U. C. Hospital
7932-7959

No. of Per

Cause Cases Cent

Surgical Operation 51 45.2

Abdominal total hysterectomy 31

Radical (Wertheim) hysterectomy 11

Vaginal repair 2

Vaginal hysterectomy 1

Abdominal subtotal hysterectomy 1

Abdominal cervicectomy (stump) 1

Miscellaneous procedures 4

Malignant Disease 38 33.6

Radiation Therapy 11 9.7

Obstetrical 11 9.7

Difficult forceps delivery 10

Cesarean section 1

Other Causes 2 1.8

Granuloma inguinale 1

Erosion of indwelling catheter 1

Total 113 100

while the other two were defects which occurred as
a result of radical operation for malignant disease.

In 58 patients operative procedures of one kind
or another were done for repair of the fistula. There
were 69 operations done, most of them being de-
signed to close the fistulous opening (Table 2).
Twelve by-pass operations were carried out, seven
by uretero-sigmoidostomy and five by ileal bladder
substitution.

The vaginal approach, which was the one most
often employed, was used in 40 instances. In six of
these, the Latzko4 technique was followed. The ab-
dominal approach was followed in ten instances —
transvesical in five, and either transperitoneal or
combined transperitoneal and transvesical in five.
There were four cases in which a combined trans-
vesical and vaginal approach, according to the
method of Twombly and Marshall,10 was used.
These were large fistulas associated either with im-
pairment of blood supply, such as may occur follow-
ing irradiation for malignant disease, or defects in
which it was not possible to gain sufficient mobili-
zation of tissue surrounding the fistula to effect
closure without tension.

RESULTS

Thirty-eight of the 46 patients who underwent
one or more surgical repairs were cured of their
fistula. In general, the vaginal approach was more
effective than the abdominal (Table 3) . The Latzko4
technique was particularly successful. In the six
cases in which it was used the fistula was closed and
no further repair was necessary.

The bladder by-pass procedures were done on
patients in whom it was thought that repair of the
fistula was impossible or inadvisable. In a few of
these cases the indication was malignant disease

VOL. 97, NO. 4 • OCTOBER 1962

TABLE 2. — Operations for Vesico-Vaginal Fistula 158 Patients,
69 Operations I, U. C. Hospital, 7932-7959

No. of

Operations Operations

Repairs 54

Vaginal 40

Abdominal 10

Combined 4

Bladder By-Pass 12

Uretero-sigmoidostomies 7

Ileal bladder substitution 5

Electrocoagulation 2

Bladder Reconstruction 1

Total 69

TABLE 3. — Results of Vesico-Vaginal Fistula Repairs 146 Patientsl

No. of No. Per

Approach Operations Cured Cent

Vaginal 40 29 72.5

Abdominal 10 6 60.0

Combined 4 3 75.0

Total 54 38* 70.4

*82.6 per cent of patients cured after one or more repairs.

TABLE 4. — Factors Contributing to Repair Failure in Vesico-
Vaginal Fistula, U. C. Hospital, 1932-1959

No.

Cases

Impaired blood supply (post Wertheim or radiation).. 3

Bladder distention postoperative 3

Persistent carcinoma 2

Trauma (vaginal examination postoperative) 1

Technical difficulties in repair 1

Unknown (poor wound healing) 6

involving the vesico-vaginal septum, but in several
instances this operation was done after one or more
attempts at repair had failed. Of the seven patients
who had bilateral uretero-sigmoidostomy, two died
of overwhelming pyelonephritis in the immediate
postoperative period. Subsequently five ileal blad-
der substitution operations were done without that
problem arising.

Factors Contributing to Repair Failure. An at-
tempt was made to assign factors which were
considered partially or completely responsible for
failure of repair in the 16 operations that were
unsuccessful (Table 4). In six instances no such
cause could be discovered and the failure was at-
tributed to poor wound healing. Impaired blood
supply (following radiation therapy or radical
hysterectomy) was considered a factor in three
cases. In three others failure was related to post-
operative bladder distention due to an obstructed
catheter, and these were considered preventable
accidents, as was the single instance of breakdown
following a vaginal examination postoperatively.

217

Persistent carcinoma was responsible for two fail-
ures, while technical difficulties at operation pre-
vented satisfactory closure in one patient.

DISCUSSION

There are several reasons for the increasing inci-
dence of vesico-vaginal fistula as a complication of
pelvic operations:

1. The increased emphasis on the importance of
performing total rather than subtotal hysterectomy.

2. The rising use of radical operation in the treat-
ment of pelvic malignant disease.

3. The increasing use of vaginal hysterectomy.

Fistulas that develop after radical surgical opera-
tion or extensive radiation therapy for malignant
disease most often are due to tissue ischemia and
necrosis related to these procedures, and are to be
accepted as a part of the risk of a necessarily radical
procedure. Improvements in technique have re-
duced the incidence of this complication, however.

Fistula following operation for benign conditions
is a complication that is for the most part prevent-
able and is the result of one or more errors in
surgical technique. These are, in the order of di-
minishing importance:

1. Sutures for closure of the vaginal cuff or for
hemostasis placed inadvertently through the bladder
wall.

2. Clamps placed on the anterior wall of the
vagina, inadvertently catching the bladder as well.

3. Unrecognized perforation of the bladder.

4. Inadvertent or intentional incision into the
bladder.

Total hysterectomy requires considerable bladder
mobilization in order to gain access to the cervix
and the vagina. In operations for benign disease,
use of the intrafascial technique (described by
Richardson8) will lessen the need for bladder dis-
section and will reduce the risk of bladder trauma.

It is the unusual pelvic surgeon who has not at
some time in his surgical experience inflicted direct
trauma to the bladder, either through design or be-
cause of operative difficulties. Bladder tissue heals
readily. If an injury is recognized at the time it
occurs, is properly repaired and the bladder is de-
compressed postoperatively, it will almost always
heal.

In the repair of vesico-vaginal fistulas, it is vital
that all surrounding induration have subsided be-
fore surgical closure is attempted. This may require
from three to six months. Collins2 reported that
this waiting period may be considerably reduced
through the use of cortisone preoperatively. The
patient should be in optimal nutritional status, and

the urine should be sterilized with appropriate uri-
nary antiseptics. Upper and lower urinary tract
studies need to be done before surgical repair.

Gynecologists, as a rule, prefer the vaginal ap-
proach. That it is desirable in most instances is
supported by the results in the small series here re-
ported. Moir7 reported a series of 136 cases in
which repair was done through the vagina with
only two failures. The Latzko partial colpocleisis
operation4 was designed specifically for the repair
of posthysterectomy fistula and is recommended
only for those cases in which the defect involves the
anterior wall at the apex of the vagina. It has the
disadvantage of slight shortening of the vagina,
however.

The transvesical suprapubic route is favored by
most urologists, and it has been demonstrated that
this method is feasible and safe. Miller5 stated that
there can be no good reason to oppose any safe
approach and he believes it is a good thing that the
suprapubic approach has been developed.

The combined approach, using the blow-out
patch technique of Twombly and Marshall,10 has
proved useful, particularly in dealing with the diffi-
cult post-radiation fistulas.

Attention to detail is of extreme importance in
the postoperative period, with particular attention
being paid to the maintenance of bladder decom-
pression. Three failures of repair in this series
occurred as a result of obstruction of indwelling
catheters, the distention of the filling bladder caus-
ing separation at the suture line.

Use of the bladder by-pass procedures is an ad-
mission of defeat in the repair of a vesico-vaginal
fistula and is to be considered only as a last resort.
Because of the high morbidity and, in our experi-
ence, the high mortality associated with uretero-
sigmoidostomy, this procedure is not recommended.
Ileal bladder substitution, even though a more diffi-
cult procedure, seems preferable.

CONCLUSIONS

Pelvic surgical operation is the most common
cause of vesico-vaginal fistula, and the operation of
total abdominal hysterectomy leads the list. Bladder
trauma, in many instances, may be prevented by
paying close attention to surgical technique, particu-
larly to avoiding involvement of the bladder when
incising, grasping or closing the vaginal vault.
Prompt recognition of bladder injury and proper
repair at the time of operation will prevent fistula
formation in most cases.

A variety of methods for the repair of vesico-
vaginal fistula are available, and treatment of each
case can and should be individualized. Regardless

218

CALIFORNIA MEDICINE

of the technique used, the principles remain the
same:

1. Maintain optimal nutritional status of the
patient.

2. Allow resolution of surrounding inflammatory
reaction.

3. Sterilize the urine.

4. Obtain adequate exposure.

5. Excise scar tissue.

6. Approximate broad surfaces without tension.

7. Maintain bladder decompression until union
has occurred.

University of California Medical Center, San Francisco 22.

REFERENCES

1. Benson, R. C., and Hinman, F, Jr.: Urinary tract in-
juries in obstetrics and gynecology, Am. J. Obst. & Gynec.,
70:467, Sept. 1955.

2. Collins, C. G., and Jones, F. B.: Preoperative cortisone
for vaginal fistulas, Obst. & Gynec., 9:533, May 1957.

3. Falk, H. C., and Bunkin, I. A.: The management of
vesico-vaginal fistula following abdominal total hysterec-
tomy, Surg., Gynec. & Obst., 93:404, Oct. 1951.

4. Latzko, W.: Postoperative vesico-vaginal fistulas, gene-
sis and therapy, Am. J. Surg., 58:211, Nov. 1942.

5. Miller, N. F. : Treatment of vesicovaginal fistulas, past
and present, Am. J. Obst. & Gynec., 30:675, Nov. 1935.

6. Miller, N. F., and George, H.: Lower urinary tract
fistulas in women, Am. J. Obst. & Gynec., 68:436, July 1954.

7. Moir, J. C. : Personal experiences in treatment of
vesico-vaginal fistulas, Am. J. Obst. & Gynec., 71:476,
March 1956.

8. Richardson, E. H.: A simplified technic for abdominal
panhysterectomy, Surg., Gynec. and Obst., 48:248, Feb.
1929.

9. Sims, J. M.: On the treatment of vesico-vaginal fistula,
Am. J. M. Sc., 23:59, Jan. 1852.

10. Twombly, G. H., and Marshall, V. F. : Repair of
vesicovaginal fistula caused by radiation, Surg., Gynec. &
Obst, 83:348, Sept. 1946.

YES on 22

VOL. 97, NO. 4

OCTOBER 1962

219

5-Fluorouracil In Metastatic Mammary Cancer

EUGENE W. DEMAREE, M.D., and HENRY D. MOORMAN, M.D., Pasadena

One of a physician’s most trying experiences is
to reach the end of therapeutic measures that can
he applied to a patient with residual cancer or
metastatic disease. For patients of this kind with
carcinoma of the breast, the first adjunctive therapy
was radiation, followed by the use of hormones and
further palliation by ablative surgical operation in
appropriate cases. With the advent of chemotherapy
a further procedure has been added, which in cer-
tain patients will prolong palliation and hope after
the effectiveness of other treatment has been ex-
hausted.

Of the chemotherapeutic agents available, the
most promising in our experience with breast carci-
noma has been 5-lluorouracil (5-fu). The present
communication is a report on the use of this agent
in 30 such patients in private practice who were
treated during 1961.

There was no uniformity in the status of the
patients. Included were patients who had had pre-
vious operation and some in which the lesion was
inoperable. The age range was from 36 to 75 years
at the time of mastectomy. As to severity, the range
was the originally inoperable case to one with recur-
rent cancer 16 years after operation. Before the
trial of 5-fu, 25 of these patients had been treated
with radiation, hormones or ablative operation —
singly or in combination. Eleven patients had had
ovariectomy, up to 12 years before treatment with
5-fu, and five had had bilateral adrenalectomy up
to four and a half years before.

Dosages of the chemical which were given intra-
venously, were determined in each case according
to the age, weight and general physical condition
of the patient, but the average was 15 mg. per kg.
of body weight daily for five days and then 7.5 mg.
per kg. every other day until signs of toxicity de-
veloped. After toxic symptoms subsided, one-half
to a full dose was given once or twice a week as
maintenance, the amount depending on signs of
recurrent toxicity in the patient. At the time of this
report, most of the patients had been treated con-
tinuously since the initiation of this therapy, but
several remained in remission six to ten months
after use of 5-fu was halted.

Toxicity was manifested in 83 per cent of the

From Pasadena Tumor Institute, Pasadena 1.

Presented before the Section on General Surgery at the 91st Annual
Session of the California Medical Association, San Francisco, April 15
to 18, 1962.

• Thirty patients with advanced metastatic
breast cancer were treated with 5-fluorouracil.
There were two deaths attributable to drug tox-
icity. Ten additional patients died of advancing
disease, and of this group only two showed sig-
nificant remissions as a result of drug therapy.
Of the 18 patients surviving, 17 obtained objec-
tive and subjective remission from their disease
and 12 were in complete remission from four to
fourteen months from institution of therapy. In
four of these cases, radiation therapy was com-
bined with chemotherapy.

cases, usually reversible or controllable, by one or
more of the following signs: vomiting, enteritis,
stomatitis and leukopenia.

Twelve deaths occurred during the entire course
of treatment, eight being in patients who had not
had any favorable response to 5-fu (Table 1). One
patient who had not responded to mitomycin died
with pronounced leukopenia shortly after receiving
only four and a half doses of 5-FU. Another patient,
who had had adrenalectomy two years previously,
died of adrenal insufficiency ten days after initia-
tion of 5-fu therapy. These two deaths must be
attributed to drug toxicity.

Nine patients who showed no favorable response
survived an average of 3.1 months from the initia-
tion of treatment to the date of this report, includ-
ing one patient still alive after 13 months. Of the
eight unresponsive patients who died, four had
metastasis to the liver, four to the lung and pleura.

Twenty-one patients were benefited; 20 had sub-
jective improvement, 13 had reduction of pain, 16
had objective reduction of metastatic lesions and
five a reduction or cessation of effusion.

Of the 16 patients whose treatment was initiated
during the first six months of 1961, 11 received
palliation (Table 2). Eight were still surviving —
9 to 14 months at the time of this report. Those
responding favorably to the treatment had an aver-
age survival of 11.3 months from the beginning of
treatment to date of report, as compared with an
average survival time of two months for those who
did not respond favorably to treatment.

From the review of these cases no definite cri-
teria can yet be established to predict which pa-
tients would probably benefit from 5-FU therapy.
However, the data in Table 3 showing response of
those patients who had previously had other forms
of treatment are of interest in this regard.

220

CALIFORNIA MEDICINE

TABLE 1. — Survival: 1961 to Mid-April 1962

TABLE 2. — Survival: January-July 1961 to Mid-April 1962

No. Number

Patients Type Surviving

21 Response 17

9 No response 1

Thirteen months’ remission following
three months’ therapy

Case 1. The patient, 49 years of age, was oper-
ated upon for a carcinoma of the left breast in
1953; for carcinoma of right breast in 1958. First
evidence of metastasis appeared in December 1960,
with pronounced dysphagia. X-ray studies showed
mediastinal involvement with extrinsic pressure on
the esophagus. Biopsy of right suprasternal node
was positive. A course of cobalt therapy was given
to the area and therapy with 5-FU was begun Febru-
ary 20, 1961, with six daily doses and weekly main-
tenance doses thereafter for three months. This
treatment resulted in complete relief of all symp-
toms. Examination in April 1962, including roent-
gen studies, showed no evidence of recurrence. The
patient was completely asymptomatic and had had
no treatment for ten months at the time of report.

5-FU response from bedfast condition to
normal life for eight months

Case 2. The patient, 56 years of age, had had
radical mastectomy for a duct cell carcinoma, grade
III, with axillary lymph node metastasis, in Sep-
tember 1953. Postoperative x-ray therapy was given
to the axilla. The patient remained well until Au-
gust 1959, then was found bedfast with a pleural
effusion and was given mustargen. This was fol-
lowed by x-ray and androgen therapy with only
slight benefit. In January 1961 (15 months later)
cervical node metastasis and pleural effusion re-
curred. 5-FU was given to the point of toxicity, the
patient then was maintained on weekly injections
for nine months. During this period 5-FU was the
only treatment, and it provided complete palliation
(freedom from symptoms and disappearance of
bilateral effusion and cutaneous metastases) until
October 1961, when effusion developed suddenly
and the patient failed to respond to further 5-FU
therapy. Death occurred two months later.

Excellent result from 5-FU alone, following bilateral
ovariectomy and adrenalectomy

Case 3. A 47-year-old woman had had radical
mastectomy for infiltrating duct cell carcinoma,
grade II, without axillary node metastasis, in June
1956. Cervical node metastasis developed in June
1960 without any other demonstrable disease, and
bilateral ovariectomy was performed. Five months
later metastatic involvement of mediastinum was
demonstrated, and bilateral adrenalectomy was per-

Average Me

>nths

Cases Type Surviving

Palliation

Survival

11 Response 8

7.4

11.3

5 No response 1

3.1

16 All cases 9

8.2

TABLE 3.— 5-FU Response Related

to Form of Preceding

Treatment

Positive Response to 5-FU

Previous Treatment

No. of Cases

Per Cent

Positive androgen response

... 4

100

Negative androgen response

... 1 of 2

Positive estrogen response

.. 5

100

Negative estrogen response

... 2 of 3

Ovariectomy

... 9 of 11

Adrenalectomy

... 3 of 5

All previous treatments

24 of 30

formed. After another seven months recurrence ap-
peared in parasternal lymph nodes without other
demonstrable disease. Treatment with 5-fu was
started in June 1961 and was carried to the point
of toxicity in six days. Due to nausea and leukopenia
(4,000 leukocytes per cu. mm.) the drug was dis-
continued for two months. In September the liver
edge became palpable and 5-fu was given as a
weekly maintenance dose of 10 cc. for the next
three months. On April 2, 1962, the patient’s gen-
eral condition was excellent and there was no
demonstrable disease. At the time of this report
the interval since 5-fu was started had been ten
months and the drug was still effective — a longer
period of palliation than that provided by ovariec-
tomy or adrenalectomy.

1 i i

It is our belief that 5-FU is an anticancer drug
capable of producing significant and most gratify-
ing remissions in the treatment of patients with
metastatic breast cancer in whom other methods of
treatment have been exhausted.

We believe that it is a valuable adjunct to radia-
tion therapy in cases where the metastatic disease is
localized to one area.

In general, patients who have responded well to
hormone or ablative therapy will respond well to
chemotherapy.

As 5-fu is a toxic drug, great care must be ex-
ercised in its use in patients with far advanced
disease or patients who have had previous chemo-
therapy or extensive irradiation. Patients who have
had adrenalectomy should be hospitalized during
the initial drug therapy, which is carried to the
point of toxicity, and carefully observed for signs
of adrenal insufficiency.

The Pasadena Tumor Institute, 635 East Union Street, Pasadena 1
( Demaree ) .

VOL. 97. NO. 4 • OCTOBER 1962

221

Ingrown” Nails and Other Toenail Problems

Surgical Treatment

MARSHALL W. JOHNSTONE, M.D., Pasadena

Treatment for relief of patients suffering from the
miserably painful “ingrown toenail” need not be
prolonged or painful or unduly complicated. Simple
surgical principles applied with some knowledge of
the anatomic features of the toenail and of the
common causative factors suffice. The operation can
be done in a physician’s office.

Anatomic features of the toenail are illustrated in
Figure 1. The nail plate begins 3 to 4 mm. proximal
to its visible base. The matrix, from which it grows,
extends from about 7 or 8 mm. proximal to the
visible base of the nail to the distal margin of the
crescent, visible beneath the nail, called the lunula.
The matrix forms the nail. The nail plate grows out-
ward, sliding over the nail bed, to the tip of the digit.
It is quite important to remember that the nail plate
is wider than the visible portion, the edges being
hidden in the nail grooves, covered by the nail folds
on either side. These hidden edges are soft and tend
to tear raggedly across when the nail is trimmed in a
rounded manner. In the permanent removal of part
or all of the nail matrix, it is important to note that
the matrix is wider than the nail plate and starts
considerably more proximal than the base of the
nail plate, especially in the corners.

ETIOLOGY

Various observers’ experiences seem to have led
to widely diverse impressions as to the importance

Submitted February 26, 1962.

• Appropriate office treatment for “ingrown”
or deformed toenails can bring quick and last-
ing relief. The principle is the removal of the
portion of the nail that irritates. For mild prob-
lems, a buried nail corner or spur may be suc-
cessfully trimmed away without anesthesia. More
extensive infection requires a nerve block anes-
thetic of the toe and removal of a wide triangle
of deformity with nail edge and the mass of
heaped up granulations.

Chronic or recurrent infection is often asso-
ciated with some abnormality of the nail. It
usually saves time and suffering in the long run
to remove a third or so of the width of the nail
together with its matrix or “root.” Sharp dis-
section is relatively easy and far more depend-
able than other methods of removal or destruc-
tion of the matrix. The matrix of the entire nail
can be removed just as easily to eliminate such
problems as the grossly thickened nail of
onychogryphosis.

of the various factors leading to “ingrown toenail.”

In my experience the order of frequency of various
etiological factors is :

1. Improper trimming of nails, leaving a ragged
corner or sharp spur hidden in the nail groove when
the nail was cut rounded (Figure 2) .

2. Acute trauma or chronic pressure lacerating
the nail groove flesh against the nail edge. Short or
too narrow shoes and stockings are a major cause
of the chronic pressure problem. The pressure may
be of a shoe against the medial edge of the nail or,

Figure 1.— Anatomic features. Note especially the relations of the visible nail, nail plate and matrix.

222

CALIFORNIA MEDICINE

Figure 2. — Left, Mild inflammation. The necessary pr
severe infection — indication for removal of large triangle

more commonly, from the impingement of the lat-
eral side of the great toe against the second toe.

3. Anatomical variations that seem to contribute
in one way or another to recurrence or chronicity
are often indications for the more radical operation
to be described later in this communication. These
include (a) too wide or obliquely growing nails,
which exaggerate the pressure of the shoe or the
second toe against the nail edge, (b) inward curling
nail edges (seen almost exclusively in adults), (c)
flabby flesh that tends to heap up over the nail edge
(rarely seen by the author except with active infec-
tion), (d) poor vascularity of tissue due to arteri-
osclerosis or diabetes — important in causation and
in delayed healing or even failure of healing, (e)
deep nail folds holding collections of dead skin and
dirt.

4. Infection from injudicious manipulation by the
patient or another person, usually in a patient with
poor circulation.

5. Chronic fungus infections (rarely seen by the
author) .

Secondary factors of considerable importance in
many cases are: (a) the tendency of a weak longi-
tudinal arch to allow the foot to lengthen excessively
on weight-bearing, jamming the toes into the end of
a shoe that was thought to be adequately long; (b)
high heels that make the foot slide forward, crowding
the toes into the narrowed front part of the shoe.

DEGREES OF SEVERITY: APPROPRIATE TREATMENT

“All surgical treatment,” as Fowler1 so aptly said,
“consists in either removing the nail from the nail
wall or removing the nail wall from the nail.” Al-

ocedure is trimming of the nail corner or the spur. Right,
of nail plate and excision of swollen tissue.

though usually not necessary, sometimes if infection
is acute, it is desirable to use antibiotics, hot soaks
or wet dressings, to limit ambulation and to cut
away the shoe for relief of pressure for several days
before beginning more definitive treatment. Treat-
ment varies with the degree of severity :

Mild degree of infection, such that the nail corner
can be inspected. Although disease of this order often
is treated by packing cotton under the corner or
by one of the many ingenious methods to protect
the infected nail groove from the nail edge and any
sharp corners or spurs, the necessary manipulations
are painful and return visits are expensive. Usually,
without anesthesia, it is possible to expose the nail
edge gently and trim away a triangle of nail, includ-
ing the usual sharp corner or spur left by improper
nail cutting (Figure 2, left) . This followed by appli-
cation of an antiseptic solution, hot soaks, wearing
a cut-out shoe during healing and then proper nail
trimming and choice of shoes and stockings, will
result in permanent cure in most cases.

More severe infection, with swelling and granula-
tions (Figure 2, right). In most such cases anesthe-
sia is necessary because manipulation causes extreme
pain. Injecting about 1 cc. of 1 per cent xylocaine
(without epinephrine) into the vicinity of each of
the four digital nerves at the base of the toe brings
about excellent anesthesia in 5 to 10 minutes. A wide
rubber band or small penrose drain held tight
around the toe with a hemostat limits bleeding dur-
ing the procedure. If permanent removal of the
nail appears not to be necessary — and often it is not
in cases of this degree of severity — it may be well
to combine removal of the nail from the infected
tissue and removal of the swollen and hypertrophied

VOL. 97, NO. 4 • OCTOBER 1962

223

Figure 3. — Permanent removal of nail edge. A, incision; B, skin (laps turned, nail split and portion being sepa-
rated by blunt dissection; C, incision through matrix and nail bed. Nail bed and nail fold being dissected; D, dis-
section completed; E, operation completed; F, fourteen weeks after operation.

nail-fold overhanging the edge of the nail. To do
this, stout scissors with a sharp point are used to cut
away a large wedge of nail (Figure 2, right), care
being taken to extend the cut smoothly to the very
edge of the nail plate. The triangular piece can then
be bluntly separated from the nail bed and the lat-
eral fold. Usually a vicious-looking nail edge spur
will be found buried in the granulations. After
curettement of the granular material, a generous
ellipse of the swollen nail fold is removed, so that
after healing the lateral nail groove will be quite
shallow. The raw surfaces exposed by this procedure
heal rapidly when treated with intermittent hot
soaks and application of a small ointment-coated
dressing. By wearing a cutout shoe the patient can
walk without much pain almost as soon as the anes-
thetic wears off, but elevation of the foot for the
remainder of the day of operation is advisable.

Infections of long standing may have undermined
the nail, or extended proximally to become par-
onychia or (less commonly) may have burrowed
plantarward into the pulp. Often in these cases re-
moval of the entire nail is indicated, with whatever
additional incisions are needed to open all pockets
of infection and clear away granulated material and
debris. Removal of the nail is not likely of itself to

disturb regrowth of a normal nail, but chronic infec-
tion about the base of the nail may have so altered
the matrix that the new growth is abnormal. Care
after operation consists of keeping the foot elevated
until infection is under control, loose packing of all
opened infected pockets for one or two days, then
hot soaks and use of small, ointment-coated dress-
ings. A shoe cut to avoid pressure at the point of
soreness may be used for walking until healing is
complete.

Chronic infection associated with anatomical ab-
normalities will often necessitate choosing between
(1) going ahead immediately with the permanent
removal of part or all of the nail together with its
matrix, as described below, and (2) use of one of
the foregoing procedures as a temporary measure
for relief of acute infection before undertaking the
definitive treatment.

PERMANENT REMOVAL OF THE NAIL

The method here described for permanent removal
of all or any portion of the nail entails a minimum
of temporary disability, is cosmetically acceptable
and is suitable for use in a physician’s office. I
evolved the procedure myself after years of look-

224

CALIFORNIA MEDICINE

Figure 4. — Permanent removal of entire nail. A, incision; B, flaps turned, nail plate having been removed; C,
incision across nail bed and nail walls distal to the lunula. Beginning dissection of matrix and nail walls; D, dis-
section finished; E, operation completed; F, seventeen weeks after operation.

ing at the fragments of nail regrowing on my own
two great toes. I have since found in the literature
a few scattered descriptions of methods embodying
the same principles and apparently equally effective.

Any condition in which a narrower nail or ab-
sence of the nail might be of help is an indication
for this procedure. Such conditions would include
recurrent “ingrown toenail” in which the nail is too
wide for the toe or is growing obliquely or is
sharply curled at the edges. Also included are cases
in which pain is caused by gross thickening or
other abnormality of a nail, such as often follows
trauma or chronic infection or comes on with age.

Contraindications are (a) circulation so impaired
as to jeopardize healing and (b) active acute in-
fection. Chronic infection need not cause delay,
usually, if the wound is left unsutured and a small
piece of rubber tissue is placed for drainage.

PROCEDURE

The patient lies supine on the operating table
with knee bent and foot flat on the table surface
with the toes near the surgeon, who sits at the end
of the table. One margin or both or the entire nail

may be removed, as illustrated in Figures 3 and
4. After anesthesia is brought about as previously
described a tourniquet is applied. The incisions
should be made well away from the nail because the
matrix from which the nail grows extends wider and
higher than the nail plate — like horns (Figure 1).
The nail plate can be split with strong, sharp-pointed
scissors. The portion of nail that is to be removed is
easily separated from its bed by use of mosquito for-
ceps or a small nasal elevator. Following a cleavage
plane when dissecting the matrix from below makes
it easier to see and remove all the matrix as one
progresses, and to distinguish the tapered proximal
margin. For good visualization, retraction, the use
of binocular magnifiers and a good light are im-
portant. It must be borne in mind that the matrix,
which must be entirely removed, extends to the distal
margin of the lunula, visible through the proximal
part of the exposed nail. Any recurrence is evidence
of incomplete removal.

As a refinement the nail folds can be removed
to eliminate dirt catchers and improve the cosmetic
result. Whatever raw areas there may be at the
completion of the procedure are small enough to

VOL. 97. NO. 4 • OCTOBER 1962

225

heal rapidly. Elaborate flap operations, grafting and
partial amputations, often advocated, are quite un-
needed. Sutures should rarely be used — never when
there is any infection present. The flaps fall to-
gether well, even if packed open for a day or two
to provide drainage. Ligatures are almost never
used.

The foot is kept elevated, with a pressure dress-
ing in place, until bleeding is controlled. The patient
is then sent home with directions to return in two
days. Meanwhile he is to keep the foot elevated
nearly continuously and to loosen the bandage if
it becomes at all uncomfortable. When the patient
is again examined on returning to the office, if a
drain was used it is removed and instructions are
given to begin hot soaks. The soaks can be omitted
if there is no indication of infection. By the end
of a week a Band-Aid® is usually bandage enough.
An old shoe with the toe of the upper cut away
and the sole intact is more comfortable and better
appearing than a slipper and it should be used
until healing is complete. The patient can walk as
much as he can without discomfort after the first
two or three days. The time away from work
usually is only three to four days.

As was noted previously, regrowth is evidence
of incomplete removal of the matrix. Two patients
on whom I operated for total permanent removal
of thickened horny nails returned some time later
with definite, very thin shells of very slowly grow-
ing nail. This phenomenon was quite acceptable,
hut a surprise. I believe in each case I left behind
just a little of the lunula distal to the incision across
the nail bed. In one of the two cases microscopic
study of sections of the base of the new nail showed
that the new nail and the matrix from which it grew
corresponded to the area of the previous lunula
and did not extend as much as a millimeter be-
neath the skin. Although complete removal of a nail
matrix must include all the lunula, it is unnecessary
to remove the part of the nail bed distal to the
lunula. This distal nail bed is epithelium and al-
though when left exposed it toughens to a slightly
rough or horny surface, it probably can never
produce a true nail that needs cutting.

65 North Madison Avenue, Pasadena 1.

REFERENCE

1. Fowler, A. W.: Excision of the germinal matrix: a
unified treatment for the embedded toenail and onychorgry-
phosis, Brit. J. Surg., 45:382-387, Jan, 1958.

YES on 22

226

CALIFORNIA MEDICINE

Workmen’s Compensation in California

Compulsory insurance, to most of us, has an un-
savory connotation. Yet there is one form of insur-
ance that we are all compelled to pay, and that we
pay cheerfully: workmen’s compensation insurance.

Every time we buy a loaf of bread, every time we
buy a car, clothing or other manufactured articles,
every time we build or alter a dwelling or attend a
play or opera, part of the cost to us is workmen’s
compensation.

Workmen’s compensation insurance functions
generally as follows. Every employed person, with
a few exceptions to be mentioned, is assured that if
he is injured on the job he will receive medical care
and, if necessary, hospitalization for the duration of
his disability. He will also receive a part of the sal-
ary he loses by being off work. He will be supplied
with such articles as braces, crutches or other de-
vices that reasonably could be expected to hasten
recovery or make him more comfortable while re-
covering. In case of his death there are allowances
for funeral expenses and for benefits to survivors.
These are supplied without direct cost to the work-
man.

This was not always so, of course, and the incep-
tion and growth of the concept, chiefly in Germany
(under Bismarck) and England (during the Indus-
trial Revolution), is of interest and will be touched
on. In the United States the movement began in the
state of New York in 1910 and since then gradually
has spread to all our states, though some of the
southern states took a long time to join the ranks.

Before 1910, the situation in which an injured
workman found himself left a good deal to be de-
sired. According to Warren L. Hanna, nationally
known for his contributions in the field of work-
men’s compensation, the opportunities for redress on
the part of an injured workman were circumscribed
by English common law. Modification of this situa-
tion began to appear in the early part of the nine-
teenth century, but it was not until much later that
more specific benefits for workmen were outlined.

Until that time, and under the precepts of English
common law, the employer’s responsibilities were
vague and not very extensive. The need for change
was pointed up in the Industrial Revolution when
vast changes in manufacturing techniques, new
forms of transportation and general economic ex-

Submitted March 16. 1962.

FREDERICK A. FENDER, M.D., San Francisco

pansion forced a realignment of the relationships
between employer and employee. Even so, for a con-
siderable period after this the main provisions of
the common law prevailed.

The employer, under the common law and even
following the minor modifications mentioned, was
obligated to do only certain things. He had to pro-
vide a reasonably safe place to work. He had to
provide reasonably safe tools and appliances. He
had to be reasonably careful in hiring employees
and servants fit for the work they had to do. He had
to lay down suitable instructions for carrying out
the work to be done. He was obligated to provide
instruction for youthful and inexperienced employ-
ees in regard to the dangers that they might encoun-
ter. Here his responsibilities ended, and unless the
employee could demonstrate that the employer had
failed in one of these respects, there was little chance
of compensation for injury.

Even then a suit for damages was the only course
of action open to the employee. And, of course, a
lawsuit presented great obstacles for an employee
who was without funds and possibly ignorant. More-
over, the employer could drag out such a trial for
a considerable length of time. Possible witnesses
might drift away. And a possible witness who re-
mained on the scene naturally was reluctant to tes-
tify against an employer for fear of losing his own
job. If the case did reach the courtroom, there still
remained three formidable hurdles in the path of
redress. These were “contributory negligence,” “the
fellow servant rule” and the doctrine of “assumption
of risk.”

Contributory negligence was a common defense.
An employer often alleged that the employee him-
self had been negligent and had contributed to the
occurrence of the injury. The fellow servant rule
also was a plausible defense against an action : If an
action proceeded from the negligence of another
employee of the same master, the employer could
be judged not liable. Finally, the doctrine of as-
sumption of risk was often invoked. If an employee
was fully informed that a job he was about to under-
take was dangerous, then chose to undertake it any-
way and as a result was injured, he was apt to find
himself without recourse.

Though the foregoing probably was consistent
with Victorian ideas of fair play and justice, dis-
satisfaction with these provisions arose. Beginning

VOL. 97, NO. 4 • OCTOBER 1962

227

in England in 1880, and later in this country, some
slight modifications appeared. These, at first, were
still inadequate and the real birth date of effective
workmen’s compensation laws throughout the na-
tion, and specifically in California, could be put
down as 1911.

Even now, in various states, there is no uniform-
ity with regard to the system used. Administration
of the laws varies. Provisions of the laws, the philos-
ophy with which they are applied and the benefits
awarded differ widely in the different states. But
all. now, offer some redress in event of injury at
work.

The author once asked an otherwise friendly at-
torney for a copy of the California Workmen’s
Compensation Law. His reply was somewhat sar-
donic: “There isn’t any such thing, and if there
were you couldn't understand it.” The law in its
present form, in addition to basic provisions, is a
volume of amendments and records of rulings
handed down in specific controversies.

THE BEGINNING IN CALIFORNIA

The California laws dealing with these matters
began, in a rather halting fashion, with the Rose-
berry Act of 1911. This act was rapidly modified
and has undergone many alterations since. In Cali-
fornia, injuries to workmen are under the jurisdic-
tion of the state’s Department of Industrial Rela-
tions, through the Industrial Accident Commission.
Officers are the Governor, the Director of the De-
partment and a Chairman of Commissioners. There
are two “panels” of commissioners — one for San
Francisco, one for Los Angeles. Under them are
referees, attorneys and other officers. In most in-
stances controversy does not arise and these officers
act in a supervisory capacity — to see that orderly
procedures are followed and that the employeee’s
rights are protected.

Although the Industrial Accident Commission has
jurisdiction over the great majority of employees,
there are certain exceptions, some of which are
listed below:

• A domestic who works for one employer less
than 52 hours a week does not have to be insured
and the Commission has no jurisdiction.

• A person who is a casual worker and not part
of the employer’s trade, business or profession does
not come under the jurisdiction of the Industrial
Accident Commission.

• The newsboy who delivers papers to your
door usually has acquired ownership of the news-
paper or periodical before he delivers it. The house-
holder is not responsible for insuring him.

• Farm laborers whose earnings for the previous
year were less than $500, and whose employer has

properly rejected the provisions of the compensa-
tion laws, do not have to be insured by the farmer.

• Employees of religious, charitable or relief or-
ganizations who are paid in aid or sustenance do
not come under the compensation laws.

• Convict laborexs are not covered.

• Self-employed persons or contractors do not
have to be insured by the persons they are working
for, with the exception of the' laborer hired by an
individual to do a certain job under the individual’s
instruction.

• Another worker who is not under the jurisdic-
tion of the Industrial Accident Commission is the
occasional watchman in a non-industrial building
who is paid by subscriptions of several persons.

• A “volunteer” — somebody who might come
into another person’s home to fix a curtain rod or
revamp the kitchen without pay, does not have to
be covered.

These are not hard and fixed rules. On investiga-
tion, it may turn out that there was some element
in the case of an injured worker that came under
the jurisdiction of the Industrial Accident Commis-
sion. Accordingly, the Commission is on its guard
to work out these situations carefully and to give
the injured person whatever protection he may be
entitled to.

Following an injury the usual course of events is
as follows. An employer must, under risk of penalty,
report any injury to an employee promptly. He re-
ports to his insurance carrier (unless he is permis-
sibly self-insured) and the insurance company then
arranges for medical attention.

Medical attention usually is put in the hands of
a physician selected by the carrier. This may seem
an unfair arrangement since the injured man’s
choice of a physician is not entirely free. The free
choice of a physician has been tried in the past and
has not worked out well. The patient’s own physi-
cian may be unfamiliar with the reports and forms
required by the Commission. He may be unfamiliar
with the points to be covered in a report. In addi-
tion, the work usually is specialized, and the physi-
cian chosen by the patient may not be competent to
carry it out. So the insurance carrier selects the
physician, and usually the claimant does not object.
However, if the patient is dissatisfied with the phy-
sician to whom his case is assigned, he may com-
plain to the Commission. The Commission then will
give him the names of three physicians in whom it
has confidence, and he may elect any one of them
to conduct the medical management of the case
from then on. The injured person is cared for,
whether the situation calls for application of a sim-
ple bandage or a surgical operation and extensive
hospitalization. Payment of compensation to the

228

CALIFORNIA MEDICINE

injured person begins after a short waiting period
and continues until temporary disability has ended
and the patient is judged able to return to work.

If there is a permanent disability the case may go
to the Industrial Accident Commission for a “rat-
ing” that ostensibly compensates for the disability,
and the case is closed.

The foregoing, as was noted, is the usual pro-
cedure; but if there is a dispute over the extent of
disability, the course of events becomes more com-
plicated— of which, more later.

Other issues, such as liability or the statute of
limitations, may have to be resolved by the Indus-
trial Accident Commission, but the majority of cases
are concerned with the responsibility of the state
and the insured to an injured workman.

Let us say that a workman has an injury to his
back. The physician representing the insurance com-
pany, after rendering treatment, may report that
there is no remaining disability, or recommend a
low “rating” — say 20 per cent permanent disability.
But the workman may feel that this is a grave in-
justice. He believes he is totally or maybe 80 per
cent disabled and, rightly or wrongly, feels ag-
grieved.

The Industrial Accident Commission then may
come into the picture in a more active way. Owing
to the technicalities and legal papers to be handled,
the Industrial Accident Commission prefers that the
workman retain an attorney at this juncture, al-
though this is not mandatory.

The attorney sends the claimant to another physi-
cian of his selection, who records the case history,
examines the patient and submits his estimate of the
situation. The case is now ready for a hearing be-
fore a referee of the Industrial Accident Commis-
sion.

This hearing has the standing of our superior
courts, but is somewhat more relaxed and informal.
The presiding officer is the referee. Present are the
claimant, an attorney for the claimant and an attor-
ney for the defendant, plus any witnesses called by
either side. Physicians may or may not be among
the witnesses called for examination and cross-
examination. Testimony is recorded but not neces-
sarily transcribed at the time. Witnesses are sworn
and each side presents its case. The referee takes
the matter under advisement, and later renders his
decision.

THE INDEPENDENT MEDICAL EXAMINER

If there is a conflict of medical testimony, the sit-
uation may be still more complex. The referee may
decide on his own, just as a judge does, which tes-
timony is most credible. On the other hand, either
he or the attorney for the plaintiff or the attorney

for the defendant may request the appointment of
an independent medical examiner in order to have
a third opinion. This physician is chosen from a
panel. Usually he is a specialist — internist, ortho-
pedist, neurosurgeon or the like. Like his colleagues
who may have appeared in the original hearing, he
is not infallible and there is no assurance that his
opinion will prevail.

In any case, the function of the independent med-
ical examiner is as follows. He is required to take
an independent history and to carry out an inde-
pendent examination of the claimant, without im-
mediate recourse to other records. Then he reviews
the medical file in the case, which is usually volumi-
nous. It holds opinions on both sides and includes
a record of the legal procedures that have taken
place. The independent medical examiner thereafter
reviews the x-ray films and laboratory reports, and
possibly transcripts of testimony elicited in other
hearings or legal proceedings.

The independent medical examiner may not com-
municate with the claimant or any attorney during
his deliberations. If he wishes additional informa-
tion he must request it of the Industrial Accident
Commission, which usually gives it to him promptly.

Thereafter he prepares a summary and writes an
opinion. These are expected to be as impartial as is
humanly possible. The report of the independent
medical examiner is added to the record. The exam-
iner may be subpoenaed to uphold his opinions in
a new hearing later on.

The author of the present communication has tab-
ulated 147 cases in which he acted as independent
medical examiner. The Industrial Accident Com-
mission agreed completely or in general with 70 per
cent of his evaluations. In the remaining 30 per cent,
the Commission was more liberal than he was in 19
per cent and vice versa in 11 per cent.

A hearing before the Industrial Accident Com-
mission can be, and often is, a routine, humdrum
procedure in which each side states its case. The
referee conducts the presentation of testimony, takes
matters under consideration and, several weeks
later, renders his decision. The hearing becomes
more lively when there is a conflict somewhere along
the line. This may be in controversy between the
testimony of the claimant and the carrier or the car-
rier’s representative, or between the medical experts.
Disagreement between medical examiners is not dif-
ficult to understand. Given identical data, in the
form of history, findings on examination and the
like, physicians on either side may disagree sharply.
One may believe that there is a large degree of dis-
ability while another may conclude that disability
is minimal or nonexistent. In this connection it has
to be recalled that the physician’s history of the case
is that given to him by the claimant. The claimant

VOL. 97, NO. 4 • OCTOBER 1962

229

may misrepresent the actual chain of events and
may change his story from time to time. This may
put one or both physicians in a highly undesirable
position.

It is true that there is a medical file to fall back
on to help in resolving discrepancies in the history.
Nevertheless, the physician relies chiefly on the
story as he gets it from the claimant.

As in the superior courts, motion pictures may be
admissible as evidence. These are sometimes infor-
mative and sometimes entertaining as well. The tech-
nique used is much like that used in the familiar
“Candid Camera” show on television. The claimant
does not know he is being photographed. After tes-
timony to the effect that he has such-and-such dis-
ability, the introduction of “movies” may do a good
deal to clarify the situation.

When a lull comes during a hearing and an inter-
mission is requested, one can be pretty sure that a
projector and a silver screen will soon appear. The
operator must give assurances that the pictures were
taken at a certain place and at a certain time.

I can remember two occasions in which the re-
sult was a surprise. In one, a claimant who had
sworn to great disability was shown doing heavy
work on a truck. The claimant, who was present,
rose up and shouted, “Hey, that’s not me; that’s my
twin brother.” The referee cautioned him to be pa-
tient. Very shortly, another man, who did bear a
striking resemblance to the first, appeared on the
film and proceeded to help out with the heavy work.
In this case there was no award for the claimant.

In another that I recall, cameras were spaced over
a distance of several hundred yards. The claimant
alleged great disability as regarded his right arm
and upper extremity. He was shown emerging from
a supermarket carrying his groceries with his right
arm. Apparently he preferred to use the disabled
arm rather than its mate. The claimant was shown
not only coming out of the supermarket but walking
about a block and a half to his car, very blithely,
without shifting his load.

On the other hand, “movies” frequently do not
add much. One carrier sent a crew from San Fran-
cisco to Sacramento to photograph a claimant. The
films showed the claimant doing just about what he
admitted he was able to do — very light work, tying
up bundles, smoothing a tarpaulin, and the like. No-
body in the hearing was impressed. I can recall
other examples of the same sort in which the carrier
hoped to accomplish great things by the introduc-
tion of movies but movies failed to carry the point.

Those workmen who come under the jurisdiction
of the Industrial Accident Commission are insured
by agencies generally referred to as “carriers” or
“insurance carriers.” Federally insured workers are
not discussed in this article.

The employer who is obligated to “cover” his em-
ployees, and who does not, may find himself in
serious difficulties, and few of them risk this. Of the
“carriers” there are two main groups: the commer-
cial carriers, and the company-owned and financed
carriers acting for the “permissibly self-insured.”
One of the commercial carriers, the State Compensa-
tion Insurance Fund, has a status that is unique and
will he discussed as a subdivision of the portion on
commercial carriers.

The Commercial Carrier

As far as the author knows, any person or group
that is financially sound (this would assume consid-
able reserves) and who can point to some experi-
ence, may ask the state’s permission to serve as the
compensation insurance carrier. With the ratifica-
tion of the insurance commissioners and subject to
the rules they impose, the firm is then in business
and may seek customers.

The firm’s obligations and rights are clearly set
forth in the code and in an extensive and complex
list of precedents and rulings in special situations
that have arisen and have been adjudicated over the
years. But, in spite of the rules and regulations,
there are still, in the author’s opinion, “good” car-
riers and “bad” carriers. Some of the features of
both kinds will be discussed.

The more or less unique organization mentioned
earlier, the State Compensation Insurance Fund,
came into existence with money advanced by the
state of California in 1914. It is now entirely self-
supporting and writes about one-third of all the
compensation insurance in the state.

The “State Fund,” as it is commonly referred to,
is largely independent. It may sue or be sued re-
gardless of reference to the state. The Industrial
Accident Commission, on the other hand, exercises
a great deal of control over the Fund.

The Fund originated very soon after our state’s
first compensation laws were passed. The purposes
to be served were four. The Fund was to provide
insurance at the lowest possible cost. It was to be
in free competition with other carriers. It was sup-
posed to be a “warm” rather than a “cold” organi-
zation, and to concern itself more with moralities
than legalities. It was to carry out an educational
campaign against industrial hazards. Opinions vary
as to how successfully these objectives have been
achieved.

Permissibly Self-Insured

Some firms, such as California Packing Corpo-
ration, the Matson Navigation Company and the
local representatives of the Bethlehem Steel Corpo-
ration, are of such size and financial competence
that they are allowed to be permissibly self-insured.

230

CALIFORNIA MEDICINE

This simply means that they have been able to con-
vince the State that they are competent to run their
own insurance companies.

I once asked an attorney who is experienced in
compensation work about the general features of
the various companies and plans. His reply was to
the effect that there were good and bad carriers in
both general groups — the commercial carriers and
the self-insured firms.

Before going further it might be a good idea to
mention authorization. In most instances, when sur-
gical operation or some special examination is con-
templated by the physician, it is necessary to receive
authorization from the insurance carrier. The ne-
cessity for authorization is a nuisance. Some firms
are very cooperative and the physician may proceed
with what he has in hand and seek authorization
later. In other instances there is more difficulty.
Sometimes when a carrier is a local office of a
larger eastern firm, authorization may have to come
from the eastern office, which may be galling to a
physician who must treat a patient over a week-end,
say, and cannot reach a responsible officer of the
company for authorization.

Finally, there is a good deal of variation between
companies as to liberality of benefits. Some firms are
liberal indeed as to the benefits they disburse.
Others may rigidly stay within the obligations im-
posed by law and may have to be forced to extend
a benefit that to some observers would seem only
reasonable. Even then, compliance with orders from
above may be delayed interminably by legal ma-
neuvers.

In a great majority of cases an employer’s sym-
pathy is with the injured workman. Some of the
self-insurance funds are very liberal indeed, but
since the self-insured employer is, in effect, spending
his own money, there can be a tendency, in some
instances, to do as little for the injured workman as
the law will allow. There is, at least theoretically, a
sort of conflict of interests.

On the other hand a company that buys its com-
pensation insurance from a carrier would appear
to have no such conflict: When an employee is in-
jured, the employer gets in touch with the compen-
sation carrier and expects the carrier to do a good
job. If it does not, the employer can choose another
carrier when contract renewal time comes around.

One other inconvenience with regard to self-
insured companies is the fact that very often large
firms of the sort that self-insure, also have health
and welfare plans in addition to their compensation
insurance subdivision. It is not uncommon for these
two subdivisions to bicker between themselves as
to which should do what for the patient.

In short, our compensation procedures have, as
might be expected, good and bad points.

The good features are immediately recognizable.
The injured workman is provided with financial
protection, medical care and the various appliances
and devices that may be needed to speed his recov-
ery or lessen his handicap. The death benefits and
the pension provisions are good points.

Some of the unsatisfactory features are suscep-
tible of remedy, some not. For instance, we have no
way, except through objective tests, of determining
the true extent of disability. A malingerer or a psy-
choneurotic person who claims to have pain and
disability may receive awards to which he is not
properly entitled. It is impossible for a physician,
xeferee, or anybody else to know how much a person
suffers. Unless there is real objective evidence, the
case may be rated on subjective complaints — to the
detriment of the carrier (and ultimately of the
public) .

DIFFICULTIES OF EVALUATION

Edward 0. Allen, who has served as a referee,
an attorney and a commissioner with the Industrial
Accident Commission, has the following to say in
regard to the difficulties in evaluation.

“It would be of great value to the work of the
Commission and to the medical profession in gen-
eral, as well as to civil practice for damage claims,
if a systematic follow-up of approved compromised
claims in compensation could be established and
there could be compiled statistical information on
the sequels of all cases of traumatic neurosis, thus
affording information as to the success and failure
of this settlement mode of therapy. The Commission
at one time was about to inaugurate such a system
and employ investigators, but an economy urge in
one of the incoming state governors put a stop to
it in the budget. The writer, in several cases of al-
leged traumatic neurosis, where as referee he urged
settlement which was approved, happened to learn
by accident long after the case was concluded that
there was full and permanent recovery to normal
after the payment of the compromise.”

Another inequity arises, it seems to me, in the
method of determining the amount of weekly com-
pensation to be paid. This is designed to be less
than the claimant could make if he were at work,
so that there may be some incentive for him to get
back to the job. I have encountered, however, inci-
dents in which, through a combination of benefits
received through other insurance organizations,
from other “sick benefits,” social security and other
like sources, the injured person’s income, combined
with his compensation, added up to a good deal
more than he could get by working. There is no
pecuniary incentive in such circumstances to get
back to work. Moreover, in weekly payments the
law makes no distinction between a single man who

VOL. 97. NO. 4 • OCTOBER 1962

231

has no dependents and the worker who, in addition
to himself, may have to support a wife and several
children on what the state allows him.

Difficulty also arises in the rating system. Take,
for example, the matter of dealing with laborers.
For some of them, hard labor is all they are able to
carry out. For the Commissioner to assign, say a
20 per cent disability to a worker of that kind is
unrealistic. Actually, if • the injured man can do
nothing but hard work, and is disabled for this, he
is 100 per cent disabled. Often there is no prospect
of educating him. The suggestion that he go to work
as a watchman or an elevator operator is not help-
ful if there are no such jobs to be had.

A great deal has been said about rehabilitation
for such persons. Harry Bridges in a recent televi-
sion appearance mentioned this as a possibility
in coping with the unemployment problem that will
be raised among the longshoremen by mechaniza-
tion. President John F. Kennedy, in a recent mes-

sage, urged education and rehabilitation for other
displaced workers. It is the writer’s feeling that
these measures will have a very limited success.

Finally, I think it is quite apparent that awards
under the workmen’s compensation set-up will con-
tinue to be more liberal. Compensation is being
awarded in more and more instances of “stroke”
and heart disease. Through changes in the Labor
Code injured members of the Highway Patrol and
city policemen and city firemen (this excludes
stenographers, telephone operators, et cetera) are
entitled, regardless of the period of service, to leave
of absence with full salary up to the period of one
year.

It seems to the writer that compensation, medical
benefits, social benefits and even the attempts at
rehabilitation, eventually will come together under
one protective blanket — the blanket that ex-Presi-
dent Dwight Eisenhower has called “government by
big brother.”

2209 Webster Street, San Francisco 15.

YES on 22

232

CALIFORNIA MEDICINE

Post-Tuberculous Bronchiectasis

Indications for Surgical Treatment

NEAL C. HAMEL, M.D., JOHN N. BRIGGS, M.O., and
THOMAS A. SCHULKINS, M.D., Encino

Pulmonary resection is firmly established as the
most effective treatment for patients with symptoma-
tic bronchiectasis. In the present study, dealing with
post-tuberculous patients who were examined to
determine whether or not they had bronchiectasis,
the main emphasis is on the indications for resec-
tional operations.

Significant bronchiectasis was demonstrated in
212 of 308 post-tuberculous patients who were
bronchoscopically and bronchographically examined
in the years 1955-1959. Pulmonary resectional op-
erations were performed in 105 of them.

Post-tuberculous bronchiectasis is defined as cy-
lindrical or sacular dilatation of the bronchial tree
occurring in an area of previous tuberculosis. The
extent of the previous tuberculosis does not always
indicate the degree of post-tuberculous bronchi-
ectasis.

Indications for pulmonary resection in post-tuber-
culous bronchiectatic patients (Table 1) are as
follows:

1. Presence of symptoms: episodes of hemoptysis,
recurrent pneumonitis or occasional sputum posi-
tive for M. tuberculosis which cannot be explained
on any other basis: More than half of the patients
in the present study who underwent operation were
in this category.

2. Bronchiectasis that is located in poor drainage
areas of the lungs, such as the lower lobe, the
middle lobe or the lingula. Many of these patients
have the symptoms noted in the first category.

3. Bronchiectasis co-existent with bronchosteno-
sis, atelectasis or large amounts of residual fibronod-
ular disease.

4. Bronchiectasis in a young patient in whom it
is the only post-tuberculous residual. This group is
rather small and the condition represents a relative
indication for resectional operation.

The kinds of operation and the numbers of cases
in which they were done in the present series are
shown in Table 2. Segmental resection for bron-

Submitted March 23, 1962.

• Two hundred twelve of 308 post-tuberculous
patients were found to have significant bron-
chiectasis; and in 105 of them, in whom certain
symptoms or combinations of symptoms and
conditions were observed, resectional opera-
tions were carried out. Good results were ob-
tained in 81 per cent of the group. There were
serious complications in 13 per cent. Three of
the patients died, two after pneumonectomy, one
after lobectomy plus segmental excision.

chiectasis is not commonly used by the authors
because of higher incidence of morbidity than with
lobectomy. The relatively high incidence of pneu-
monectomy in this series was due to severe bron-
chiectasis combined with atelectasis and fibrosis — a
process that is commonly called “destroyed lung.”
Complications occurred in 19 per cent of cases,
serious complications in 13 per cent (Table 3).
Good results were obtained in 81 per cent of the
group. Two of the three deaths were associated with
pneumonectomy. The remaining death was in a

TABLE 1. — Indications for Resectional Operation in Post-
Tuberculous Bronchiectasis

1. Symptomatic

a. Bleeding

b. Recurrent pneumonitis

c. Occasional recurrent positive sputum

2. Inadequately drained

a. Lower lobe

b. Middle lobe

c. Lingula, etc.

3. Co-existing with

a. Bronchostenosis

b. Atelectasis

c. Large amounts of residual fibronodular disease

4. In the occasional young patient in whom it is the only
post-tuberculous residual

TABLE 2. — Types of Resectional Operation in 105 Cases of
Post-Tuberculous Bronchiectasis

1. Lobectomy 42

2. Pneumonectomy 36

3. Lobectomy and segmental 15

4. Segmental 4

5. Multiple segmentals 6

6. Bilateral resections 2

VOL. 97. NO. 4 • OCTOBER 1962

233

TABLE 3. — Complications in 105 Resections for Post-Tuberculous
Bronchiectasis

Deaths* 3

Broncho-pleural fistulae

a. Temporary 2

b. Prolonged* 3

Empyema* 3

Respiratory insufficiency* 5

Hemothorax 2

Wound infection 1

Postoperative pneumonia 1

Summary of results:

Total complications 20 (19%)

Serious complications 14 (13%)

Good results 85 (81%)

* Serious results are marked with an asterisk.

patient who had lobectomy plus segmental excision,
a resectional combination which in the authors’
experience is associated with a relatively high mor-
bidity rate. When the original disease extends well
beyond the confines of a lobe, we often recommend
a pre-resection thoracoplasty to help avoid the mor-
bidity associated with resection which includes more
than a lobe. Postoperative respiratory insufficiency
was noted in five patients. We are devoting more
attention to this complication which is largely pre-

ventable by better preoperative evaluation and in-
tensive pulmonary studies when indicated. Cardiac
catheterization has proven to be an aid in some of
the more difficult preoperative decisions.

DISCUSSION

Post-tuberculous bronchiectasis is relatively com-
mon in patients who have had recurring tubercu-
losis. The mere presence of the condition is not a
direct indication for operation, but careful evalua-
tion of these patients reveals a relatively high
incidence of symptoms associated with it. These
symptoms include hemoptysis, recurring pneumoni-
tis and, at times, sputum persistently positive for M.
tuberculosis. Bronchiectasis is often associated with
bronchostenosis, atelectasis and large amounts of
residual fibronodular disease. When bronchiectasis
is located in poor drainage areas such as the lower
lobe, the middle lobe or the lingula, resectional
operation may be indicated. Surgical excision may
be recommended for younger patients in whom mod-
erate to pronounced bronchiectasis remains as the
only visible residual of a previous tuberculous
process.

16100 Ventura Boulevard, Encino (Hamel).

YES on 22

234

CALIFORNIA MEDICINE

CASE REPORTS

Hypernephroma — Disappearance of
Metastasis After Nephrectomy

R. J. PRENTISS, M.D., F. G. HOLLANDER, M.D.,
R. B. MULLENIX, M.D., M. J. FEENEY, M.D., and
G. E. HOWE, M.D., San Diego

Host resistance affects the development of ma-
lignant tumors, as do the biologic potential of the
tumor and genetic factors. However, the exact rea-
sons for disappearance of metastatic lesions after
removal of the primary tumor, are not clear.1"4

In the present case, as in many another reported
in the literature, pulmonary lesions metastatic from
a hypernephroma disappeared after the primary
tumor was excised.

REPORT OF A CASE

The patient, a 63-year-old woman, entered the
hospital in 1947 with complaint of gross hematuria
associated with right renal colic. Secondary com-
plaints were weakness and a heavy mobile mass in
the right side of the abdomen. Upon physical exam-
ination, pallor, moist rales in both lungs and the
presence of a round, smooth, movable mass 15 cm.
in diameter in the right flank, were noted.

Results of laboratory studies showed hematuria,
pyuria and moderate secondary anemia. The blood
urea nitrogen was normal.

In excretory urograms the left kidney and the
bladder appeared normal. On the right, pelvic and
calyceal deformity typical of renal neoplasm were
visualized. Multiple large bilateral pulmonary met-
astatic lesions were seen in a film of the chest.

The diagnosis was: Hypernephroma, right, with
pulmonary metastasis. Informed that the situation
was incurable, the patient insisted on surgical re-
moval of the kidney to relieve pain and bleeding.
But also she said, “Doctor, if you remove the
mother, the daughters will disappear.”

Therefore, at the insistence of the patient and the
family, and for the relief of local discomfort, right
nephrectomy was performed and at operation the
pedicle and the renal vein were observed to be in-
volved in the tumor.

The specimen was typical hypernephroma weigh-

Presented before the Section on Urology at the 91st Annual Ses-
sion of the California Medical Association, San Francisco, April 15
to 18, 1962.

Figure 1. — Gross specimen of hypernephroma removed.

Figure 2. — Photomicrograph of sections of hyperne-
phroma removed (X430).

VOL. 97. NO. 4 • OCTOBER 1962

235

Figure 3. — Chest film three months after removal of
primary lesion (in 1947), showing multiple metastasis
presumably from hypernephroma.

ing 540 grams (Figure 1). The pathologist found
the renal vein blocked by tumor. Upon microscopic
examination it was observed to be clear cell hyper-
nephroma, grade IV (Figure 2).

The patient’s health has been excellent in the 15
years since the operation. Films of the chest were
taken occasionally during that time. Multiple areas
of metastasis were still present three months after
nephrectomy (Figure 3) but ten months later the
chest was completely free of metastatic lesions, as it
was when the most recent film was taken, early in
1962 (Figure 4). Upon examination of the patient,
of a specimen of urine and of the remaining kidney,
no evidence of disease was found. She was in good
health and felt well.

DISCUSSION

We have performed nephrectomy on three other
patients with pulmonary metastasis from hyperne-
phroma without altering the progression of the dis-
ease. However, we believe that nephrectomy is justi-
fied even though there may be distant metastasis,
not only to relieve pain and stop hemorrhage from

Figure 4. — Latest chest film (1962) showing no meta-
static lesions.

the kidney, but in the hope that secondary metasta-
tic areas will regress. We never hesitate to advise
nephrectomy in the presence of distant metastasis
from hypernephroma. Other observers have reported
removing solitary metastatic areas from the chest,
from the renal incision and even from bone. In gen-
eral, excision of recurrent tumor growth at the orig-
inal or at distant sites is not wise; but in the case
of hypernephroma it must be seriously considered,
as occasional cures or control may he expected.

3415 Sixth Avenue, San Diego 3 (Prentiss).

REFERENCES

1. Everson, T. C., and Cole, W. H.: Spontaneous regres-
sion of malignant disease, J.A.M.A., 169:1758-1759, 1958.

2. Ljunggren, E„ Holm, S., Karth, B., and Pompeius, R.:
Some aspects of renal tumors with special reference to spon-
taneous regression, J. Urol., 82:553-557, 1959.

3. Macdonald, I.: Biological predetermination in human
cancer, Surg., Gyn. & Obstet., 92:443-452, 1951.

4. Samellas, W., and Murks, A. R.: Apparent spontane-
ous regression of pulmonary metastases following nephrec-
tomy for adenocarcinoma of the kidney, J. Urol., 85:494-
496, 1961.

YES on 22

236

CALIFORNIA MEDICINE

For information on preparation of manuscript, see advertising page 2

DWIGHT L. WILBUR, M.D Editor

ROBERT F. EDWARDS . . . Assistant to the Editor

Policy Committee — Editorial Board

OMER W. WHEELER, M.D. . . Riverside

SAMUEL R. SHERMAN, M.D San Francisco

CARL E. ANDERSON, M.D Santa Rosa

JAMES C. DOYLE, M.D Beverly Hills

MATTHEW N. HOSMER, M.D San Francisco

IVAN C. HERON, M.D San Francisco

DWIGHT L. WILBUR, M.D San Francisco

EDITORIAL

Medical Assistance to the Aged

In 1960 the congress enacted the Kerr-Mills bill
to provide federal assistance to states and coun-
ties in the provision of medical care for aged
citizens who did not qualify for such aid under the
welfare laws. The aim of the act was to assure ade-
quate and proper care for citizens above the age of
65 years who could meet their normal living needs
but could not meet the costs of medical care under
their current budgetary needs.

In 1961 the Legislature of the State of California
enacted the Rattigan Bill, which provided that the
state would meet one-quarter of the cost of such
care, on the basis that the counties would also pay
one-quarter and the federal government one-half.

The Rattigan measure went into effect January 1,
1962, and in the first six months applications for
assistance were received from close to 26,000 citi-
zens. As of the end of June, the latest month for
which certified figures are available, more than
15,000 persons were certified as eligible for Kerr-
Mills assistance in California.

Expenditures under the program amounted to
about $18 million in the first six months. The budget
for the first year had been estimated at $80 million.

On this brief recital it becomes evident that the
program has operated to the benefit of a large num-
ber of citizens and that it has stayed well within its
fiscal limitations, even if we allow for unfiled claims
that may swell the cost figures.

It is also a political fact of life that this program
has been accomplished through the use of general
tax funds and outside the social security structure
of the federal government, as the King-Anderson
proposal would have demanded. The people have
accepted the Kerr-Mills plan as a social responsi-
bility but have rejected the proposition that it he
converted into a bureaucratic vote-getter.

With the experience gained in the California pro-
gram to date, it is obvious that some amendments to
the original Rattigan Act and its consequent regula-

tions are now due. Such amendments may he placed
before the Legislature in its next session, starting
in January.

Fortunately the California Medical Association
has maintained liaison with the State Department of
Social Welfare, which administers this and other
medical welfare plans. The liaison committee has
maintained contact with all aspects of the plan and
has now made recommendations for amendments in
the interest of the beneficiaries, the state and the
physicians.

First of these recommendations is that the patient
be placed on a dollar-deductible basis to qualify for
service, rather than on a calendar day basis. Today
an applicant must show that he has paid his own
way through 30 days of hospitalization or nursing
home care. The liaison committee suggests that a
dollar-deductible basis, such as $400, be used in-
stead of a 30-day period, since there may be a wide
variation in the costs as between one kind of hos-
pital facility and another and between costs of treat-
ment for varying causes.

The committee also feels that some flexibility
should be introduced into the determination of eligi-
bility and that preceding hospitalization should not
be singled out as the sole determinant. This exclu-
siveness, the committee states, is not “. . . medically,
socially or economically proper or necessary.”

Also recommended as an area for amendment is
the portion of the existing law which places a dollar
limitation on the personal property an applicant
may possess and remain eligible. The effect of this
provision appears to make home ownership desir-
able but ownership of income-producing personal
property undesirable. A family living on the in-
come from a modest investment pool may, under
present requirements, be forced to destroy the in-
vestments— and thus do away with income in the
post-care period — in order to qualify for care under
the present law. This determination might more
properly he made through discretionary administra-

VOL. 97. NO. 4 • OCTOBER 1962

237

tion which looks to the protection of the patient as
well as the county.

Changes are also indicated in the present restric-
tions against a beneficiary receiving aid in one calen-
dar month from both the welfare program (O.A.S.)
and the aid to the aged program (M.A.A.). Present
restrictions do not allow consecutive assistance from
both plans in one calendar month. Medically, the
patient’s needs cannot be served on a calendar basis,
and regulations to place the needs of the patient first
are indicated.

A fourth area of change appears in the handling
of administrative funds where California Physicians’
Service is the fiscal administrator of a county pro-
gram. Under present regulations, funds which even-
tually go to C.P.S. are handled through the county
government, a needless procedure which can result
only in confusion and delay. C.P.S. has so well
proved itself as a careful, prudent and accurate ad-
ministrator of this and other governmental pro-
grams that it should he given assistance in the

prompt receipt of state and federal funds rather
than having to wait while such funds go through the
slow-moving machinery of another governmental
unit.

These proposals for changes in the present law
will bear watching during the 1963 session of the
Legislature. Each must, of course, be documented
adequately and for each an author must be found.
On some there may be objections by state authori-
ties, while others may well find acquiescence and co-
operation.

The California Medical Association has firmly
supported the concept under which the Kerr-Mills
legislation went through the Congress. It has sup-
ported the Rattigan legislation to bring the state into
its proper place in this program. It now supports
amendments to the original law which will provide
for a more adequate, more equitable and more easily
administered program for the benefit of our older
citizens.

Medical Education Loans

A FAR REACHING new medical education loan guar-
antee program is now under way in American
medicine. The goal of this program is to help
eliminate the financial barrier to medicine for all
who are qualified and accepted by approved training
institutions. It is designed to provide a means of
financing a substantial portion of the cost of a
medical education.

The loan program for medical students, interns
and residents is the result of a cooperative effort by
American medicine and private enterprise.

The program is administered by the American
Medical Association’s Education and Research Foun-
dation. The E.R.F. has established a loan guarantee
fund. On the basis of this fund, the bank will lend
up to $1,500 each year to students. The E.R.F. in

effect acts as co-signer. For each $1 on deposit in
the E.R.F’s. loan guarantee fund, the bank will lend
$12.50.

More than 3,300 students, interns and residents
have borrowed more than $6,000,000 through this
fund since it was started last February. Physicians
and others have contributed almost $700,000 to the
loan guarantee fund, which makes possible these
loans.

The guarantee fund is almost depleted and more
money is needed immediately to keep up the loan
program. Eventually it will become self-sustaining
as loans are repaid, but right now substantial finan-
cial help is needed. Your check to the A.M.A.-E.R.F.,
535 North Dearborn St., Chicago, will help to keep
this important program viable. Contributions to the
Foundation are tax deductible.

YES on 22

238

CALIFORNIA MEDICINE

NOTICES & REPORTS

Council Meeting Minutes

Minutes of the 483rd Meeting of the Council, Los
Angeles, Ambassador Hotel, August 25, 1962.

The meeting was called to order by Chairman An-
derson in the Ballroom of the Ambassador Hotel. Los
Angeles, on Saturday, August 25, 1962. at 10:00 a.m.

Roll Call:

Present were President Wheeler, President-Elect
Sherman, Speaker Doyle, Vice-Speaker Heron, Sec-
retary Hosmer, Editor Wilbur and Councilors Mac-
Laggan, Wilson, Todd. Quinn, O’Neill, Bullock,
O’Connor, Rogers, Dalton, Murray, Davis, Miller,
Watts, Campbell, Morrison, Anderson and Dozier.
Absent for cause, Councilors Ham and Kaiser.

A quorum present and acting.

Present by invitation were Messrs. Hunton,
Clancy, Clark. Marvin, Whelan, Tobitt and Bow-
man, Doctors Batchelder and Miller and Mrs. Grif-
fith of C.M.A. staff; Messrs. Hassard and Huber of
legal counsel, county executives Rosenthal of the
Forty First Medical Society, Scheuber of Alameda-
Contra Costa, Lingerfelt of Fresno, Geisert of Kern,
Dalbec and Baker of Los Angeles, Bannister of Or-
ange, Brayer of Riverside, Dochterman of Sacra-
mento, Nute of San Diego, Grove of Monterey,
Neick of San Francisco, Colvin of Santa Clara,
Brown of Sonoma and Rideout of Butte-Glenn;
Willis Babb of California Physicians’ Service; Bob
Garrick, campaign director; Doctors Warren L. Bos-
tick. T. Eric Reynolds, Joseph P. Cosentino, John
Field, Benjamin Wells, George Y. Abe, Eugene F.
Hoffman, Arthur R. Albin and Robert F. Schell.

1. Minutes for Approval:

On motion duly made and seconded, minutes of
the 482nd Council meeting, held July 7, 1962. were
approved.

2. Membership :

fa) A report of membership as of August 22,
1962, was presented and ordered filed.

(b) On motion duly made and seconded, 80 de-
linquent members, dues now paid, were voted re-
instatement.

(c) On motion duly made and seconded in each
instance, 11 applicants were voted Associate Mem-
bership. These were: James T. Harrison. Robert A.
Loeffler, Alameda-Contra Costa; Robert A. Herrick,
Joseph G. Stroup, Marin County; Austin Matthis,
Sacramento County; William C. Adams, Carl E.
Lengyel, San Diego County; Ernest P. Guy, San
Francisco County; Florence A. Toussaint, Santa
Clara County; Carl V. Reichman, Tehama County;
Avron M. Greene, Ventura County.

( d ) On motion duly made and seconded in each
instance, two members were voted Retired Member-
ship. These were Doctors Joseph L. Schwartz. Sr. of
Los Angeles County and Joseph W. Sooy of Napa
County.

(e) On motion duly made and seconded in each
instance, two members were voted reduced dues for
postgraduate study.

3. Communications Study:

Mr. James E. Bryan presented a report on the
study of communications made by him for the Coun-
cil. The report, which contained 34 specific recom-

OMER W. WHEELER, M.D President

SAMUEL R. SHERMAN, M.D President-Elect

JAMES C. DOYLE, M.D Speaker

IVAN C. HERON, M.D Vice-Speaker

CARL E. ANDERSON, M.D. . . Chairman of the Council
BURT L. DAVIS, M.D. . . Vice-Chairman of the Council

MATTHEW N. HOSMER, M.D Secretary

DWIGHT L. WILBUR, M.D Editor

HOWARD HASSARD Executive Director

JOHN HUNTON Executive Secretary

General Office, 693 Sutter Street, San Francisco 2 • PRospect 6-9400

ED CLANCY Director of Public Relations

Southern California Office:

2975 Wilshire Boulevard, Los Angeles 5 • DUnkirk 5-2341

VOL. 97. NO. 4 • OCTOBER 1962

239

mendations, was, on motion duly made and sec-
onded, received.

The Council then reviewed the recommendations
made in the report and specified that recommenda-
tions 1, 2, 3, 6, 7, 8, 9, 11, 16, 17, 18, 19, 25, 26, 27,
28 and 30 be referred directly to the Bureau on
Communications for implementation. Recommenda-
tion No. 14 was referred to the Bureau on Commu-
nications and the Finance Committee jointly and
recommendation No. 24 was referred to the Bureau
of Research and Planning.

On motion duly made and seconded, it was voted
to establish an ad hoc committee to study and report
back on the balance of the report recommendations.
On motion duly made and seconded, this committee
was voted to consist of the members of the Com-
mittee for Emergency Action, the chairmen of the
Finance Committee and the Commission on Medical
Services and the Board Chairman of California Phy-
sicians’ Service. On motion duly made and sec-
onded, it was voted that copies of two reports and
statements previously made by Doctor Watts be fur-
nished the members of the ad hoc committee.

4. Bureau of Research and Planning:

On motion duly made and seconded, it was voted
that a report of the Bureau of Research and Plan-
ning on the subject of marketing of medical care
should be published, subject to deletion of the word
“marketing” in the title.

5. Proposition #22:

Mr. Bob Garrick, director of the campaign to se-
cure an affirmative vote on Proposition 22 on the
November ballot, gave a progress report on his ac-
tivities and showed samples of the materials being
prepared.

6. Medical School Deans:

(a) Doctor Benjamin Wells, dean of the Califor-
nia College of Medicine, reported on the progress
of the school and expressed thanks for the assistance
he has had from committees and other members of
the Committee.

(b) Doctor Malcolm Watts, associate dean of
University of California School of Medicine, re-
quested endorsement of Proposition 1A on the
November ballot, which would provide funds for
expanded educational facilities. It was reported that
the consideration of this proposition has already
been referred to the Committee on Legislation.

7. State Department of Public Health:

Doctor Malcolm Merrill, State Director of Public
Health, gave an informal report on the World Health
Assembly in Geneva, Switzerland, which he attended
as one of a 12-man U. S. team.

Doctor Merrill also reported that more than 38
million doses of oral polio vaccine have been admin-
istered and that only 12 cases of paralytic polio
which could be connected timewise with these ad-
ministrations have resulted. Of these cases, only five
were found to be possibly associated with the vac-
cine. The department feels, he stated, that there is
no reason to withhold mass immunization using the
oral vaccine.

Councilor Campbell presented questions on a can-
cer inquiry distributed by the State Department of
Public Health. These questions were referred to the
Commission on Public Agencies with a request to
report back to the Council at its next meeting.

8. State Department of Mental Hygiene:

Doctor George Y. Abe, representing the State De-
partment of Mental Hygiene, reported that changes
are being suggested in the Short-Doyle Act and in
the commitment laws. The department would like to
discuss these matters with the Committee on Mental
Health and the Council agreed.

Doctor Abe also reported that the Governor’s
Commission on Insanity has issued a report affect-
ing the care of mentally ill criminals. A further
report will be made on this. Doctor Abe also re-
ported that Doctor Daniel Blain has received an
invitation to attend the Congress on Mental Health
of the A.M.A., for which he was tendered congratu-
lations by the Council.

9. State Department of Social Welfare:

Mrs. Eunice Evans of the State Department of
Social Welfare reported that in the first six months
of the Medical Assistance to the Aged program,
about $18,000,000 has been expended. In this
period there have been more than 25,000 applica-
tions for aid and about 17,000 cases are now on
rolls. During the most recent month, 40 per cent of
the applicants had not previously been on welfare
rolls. Mrs. Evans stated that the law permits the
department to lower from 30 to 21 days the required
period of institutional care prerequisite to eligibility
for aid and that, if experience so indicates, this
reduction will probably be made.

Airs. Evans also stated that the determination of
rates to be paid to nursing homes is in the hands of
the Department of Finance and that a sampling of
80 nursing homes is being made with a view toward
establishing standards by which a suitable schedule
of rates might be determined by the end of the year.

Doctor Todd presented a series of questions to
Mrs. Evans, the questions and answers to be digested
for the benefit of county societies and others.

Mrs. Evans also reported that aid to the totally
disabled is increasing under expanded eligibility
requirements and that aid to the blind and to needy

240

CALIFORNIA MEDICINE

children cases are decreasing. The department is
expanding its investigative force to review the
dispensing of pharmaceuticals. She will submit
figures on costs of both M.A.A. program and A.N.C.
to Liaison Committee for their information and
report hack to the Council.

10. California Physicians’ Service:

Doctor Morrison, board chairman of C.P.S., re-
viewed the national Blue Shield program for cover-
age of persons over 65 years of age and distributed
comparisons of this program with two new plans
now approved by C.P.S. for public offering. He also
stated that Blue Cross has developed a national plan
and that C.P.S. was considering a joint offering
with Blue Cross. On motion duly made and seconded,
the efforts of C.P.S. in this direction were voted
approval.

Doctor Morrison also reported that Riverside
County had withdrawn from C.P.S. fiscal agency
services in welfare cases and that other counties
were considering like action. Should this occur, he
said. C.P.S. will probably have to discontinue this
service because of the resultant high cost for the
remaining counties.

11. Medical Executives Conference :

Mr. William Scheuber reported that the Medical
Executives Conference had made several recommen-
dations on welfare programs and that the county
executives offered their services in these programs.
He also reported that Mr. Don Rosenthal, executive
director of the Forty First Medical Society, had
been voted membership in the conference.

12. Liaison Committee to Social Welfare:

Doctor Quinn presented a report for the Liaison
Committee to the State Department of Social Wel-
fare, including several suggested amendments to
the state law providing for Medical Assistance to
the Aged. Doctor John Murray reported that the
Commission on Medical Services was in agreement
with these proposals. On motion duly made and
seconded, the liaison committee report was voted
approval and it plus the report of the Commission
on Medical Services was ordered referred to the
liaison committee and to the Committee on Legis-
lation. (The Liaison Committee report is appended
hereto and made a part of these minutes.)

13. Proposed Medical Care Plan:

Doctor Arthur R. Ablin presented a report and
proposed resolution on a national medical care plan
in behalf of the Marin Medical Society. On motion
duly made and seconded it was voted to refer this
proposal to Doctor Dwight L. Wilbur, chairman of
the delegation to the A.M.A., who will name an ad

hoc committee to review the proposal and prepare
suitable material for Council consideration prior
to decision regarding submission to the A.M.A.

14. Report of the President:

Doctor Wheeler reported on his recent activities,
including the issuance of a charter to the Forty
First Medical Society and the orientation meetings
for diplomates of the California College of Medi-
cine. He also reported that the board of supervisors
in Santa Barbara County is receptive to proposals
made by the county society for the handling of
welfare programs by underwriting by California
Physicians’ Service.

15. Committee for Emergency Action :

(a) Doctor Wheeler reported on informal dis-
cussions with representatives of the State Depart-
ment of Finance. He stated that the Committee
urged the State Department to adopt the current
Relative Value Studies as its base. After discussion,
it was moved, seconded and carried that the Com-
mittee for Emergency Action continue discussions
with the State Department of Finance and continue
to urge adoption of the current R.V.S.

(b) Doctor Wheeler also reported that California
Medical Education and Research Foundation is
considering applying for a research grant to con-
duct studies in relationship to health care of sea-
sonal farm workers. It was moved, seconded and
carried that this activity of C.M.E.R.F. be ap-
proved.

16. Report of the President-Elect:

Doctor Sherman reported on a meeting with the
State Board of Medical Examiners and the deans
of the medical schools, attended by Association
officers. He suggested that the board be invited
to send representatives to Council meetings and
on motion duly made and seconded, this proposal
was approved.

17. Mass Polio Immunization Programs:

Discussion was held on the advisability of docu-
menting various mass polio immunization pro-
grams on film for later presentation on television.
On motion duly made and seconded, this proposal
was referred to the Bureau on Communications.

Doctor MacLaggan reported that the ad hoc Com-
mittee on Oral Polio Vaccine wished to inquire into
a wide variation in insurance premiums for premises
liability insurance. On motion duly made and sec-
onded, this inquiry was approved as appropriate for
the committee.

Doctor MacLaggan requested authority to look
into the possibility of securing uniform prices for
oral polio vaccine. On motion duly made and sec-
onded, this authority was granted.

VOL. 97. NO. 4 • OCTOBER 1962

241

18. Committee on Committees :

Doctor Sherman presented a series of recommen-
dations of the Committee on Committees. These
were all. on motions duly made and seconded, voted
approval. They included:

(a) Ad hoc committee to study the role of county
hospitals — John E. Vaughan, Bakersfield, chair-
man; members, John M. Rumsey, San Diego;
William D. Evans of Los Angeles, John G. Morrison
of San Leandro, A. B. Sirbu of San Francisco,
Calvin Plumhof of San Rafael and Norman Tos-
tenson of Fresno. Consultants, Doctor Norman Fox
of San Bruno representing the California Academy
of General Practice; Messrs. George Badenhausen
of Long Beach and Kenneth Rindflesh of Ventura
and Doctor William Stadel of San Diego as hospital
administrators.

(b) Ad hoc committee on the coroner law —
Lewis T. Bullock of Los Angeles, chairman; Doc-
tors Jesse L. Carr of San Francisco, Henry W. Tur-
kel of San Francisco and Hugh A. Edmonson, Sid-
ney C. Madden and Orlyn B. Pratt of Los Angeles,
with Doctors Theodore Curphey of Los Angeles and
Raymond Brandt of Orange County as consultants.

(c) Committee on Occupational Health — Doctor
Edward Zaik of Los Angeles to succeed Doctor
Joseph Sadusk of Oakland, resigned.

(d) A.M.A. Council on Rural Health — Leo Sny-
der of Fresno to be named as a candidate for this
appointment.

(e) For committee nominations — Councilors are
to consult with county society presidents to prepare
a list of nominees, together with brief biographies
of each. Lists to be submitted not later than Feb-
ruary 15, 1963, with the President-Elect to meet
with county presidents and medical executives in
January to urge early submission of lists.

(f) Doctor Sherman reported that the member-
ship of the Forty First Medical Society would en-
title that society to two members of the Council. He
proposed that Doctors Joseph Cosentino and Forest
J. Grunigen be appointed as members by the Coun-
cil for the interim period prior to the next meeting
of the House of Delegates.

(g) The Committee on Committees was given
authority to name two representatives on the Visalia
experimental program on migratory farm workers.

19. Finance Committee:

Doctor Davis presented copies of the audited
financial reports of the Association and affiliated or-
ganizations for the fiscal year ended June 30, 1962.
These were ordered filed. Doctor Davis also pre-
sented a report of income and expenditures for July,
1962, first month of the new fiscal year; this was
also ordered filed.

Doctor Davis reported on a meeting between the
Finance Committee and medical and lay represen-
tatives of the Central California Blood Bank, Fresno,
in regard to a note signed by the blood bank and
subsequently purchased at a discount by the Asso-
ciation. The committee recommended that the Cen-
tral California Blood Bank be permitted to purchase
this note on the basis of its present cost to the Asso-
ciation. On motion duly made and seconded, this
purchase was approved.

A proposed budget for the ad hoc committee to
study the role of county hospitals was presented.
On the recommendation of the finance committee
and on motion duly made and seconded, it was voted
to appropriate $2,500 for the use of this committee,
additional funds to be requested if needed.

Doctor Davis advised the Council that the Finance
Committee was considering the retention of invest-
ment counsel to make recommendations of invest-
ment procedure on investments now held but not
due for redemption until 1969 to 1972.

20. Commission on Public Agencies:

For the Committee on Other Professions, request
was made that Resolution #10 of the 1962 House
of Delegates, relating to fluoridation of water sup-
plies, be referred to the Commission on Community
Health Services for statewide meetings with dental
association representatives and others interested.
On motion duly made and seconded, this referral
was approved.

21. Commission on Community Health Services:

(a) Publication was approved, on motion duly
made and seconded, of a program of youth fitness,
to be sent to appropriate schools and others.

(b) Resolution No. 79 of the 1962 House of Dele-
gates, relating to the medical aspects of sports, was
considered by the Committee on School Health to
be too broad a subject for that committee. It sug-
gested that a special committee be named for this
subject and Doctor Sherman asked that Councilors
forward names of potential appointees to such a
committee. On motion duly made and seconded, it
was voted that the Finance Committee consider
budgetary aspects of such a committee.

22. Commission on Cancer:

Doctor Davis reported that the rewriting of can-
cer studies was progressing satisfactorily. The Pa-
tient Need Survey was in preparation for a report
which should be completed within the next two
months. He also suggested Doctor Doyle as mod-
erator for a panel at a forthcoming quackery con-
ference. On motion duly made and seconded, this
appointment was approved.

242

CALIFORNIA MEDICINE

23. Staff Report:

Mr. Hunton reported on a meeting held by repre-
sentatives of various professional organizations at
which discussion was held on the advisability of
forming an interprofessional association. The staff
will follow the progress of such meetings.

24. Legal Department :

Mr. Hassard reported that two cases are now be-
fore the State Supreme Court bearing on the judg-
ment of hospital governing boards and medical staff
committees on staff appointments. Briefs as amicus
curiae have been filed by the Association and by the
California Hospital Association.

25. New Business:

(a) Authority was voted for use of C.M.A. mail-
ing lists and facilities for publicizing the Western
Institute on Epilepsy for a scheduled San Francisco
meeting.

( b I Official approval was voted for an invitation

to the American Medical Association to hold its
1968 Annual Meeting in San Francisco.

(c) Authority was denied for a scientific section
to use the Association’s name in the promotion of
scientific programs sponsored by others. This mat-
ter was referred to the Scientific Board for consid-
eration when the hoard is formed.

26. Time and Place of Next Meeting:

Discussion was held on the date of the next Coun-
cil meeting, scheduled to be held in San Francisco
on October 6, 1962. Members of the Council are to
be polled on their opinions as to whether this date
should be advanced to September 29 because of
conflicts.

Adjournment:

There being no further business to come before
it, the meeting was adjourned at 5:15 p.m.

Carl E. Anderson, M.D., Chairman
Matthew N. Hosmer, M.D., Secretary

August 22, 1962

Omer W. Wheeler, M.D.

6876 Magnolia Avenue
Riverside, California

Dear Doctor Wheeler:

At the request of the Committee on Emergency
Action, the Eiaison Committee to the State Depart-
ment of Social Welfare has studied the problems
that have developed in the administration of the
Rattigan Act. Certain recommendations for pro-
posed amendments seemed to be in order.

Medical assistance for the needy aged ought to be
provided under state and county direction with fed-
eral and local matching funds. This concept has been
strongly supported by most members of our profes-
sion and by both the American and California med-
ical associations. This principle is expressed in the
Kerr-Mills Act.

C.M.A. supported enactment of the Rattigan Act,
which adopted this concept in California. This act
is a more effective and intelligent approach to
the problem than that taken by many other states.
Experience points the way in which it may be
improved in certain specific areas to better accom-
plish its purpose.

The medical assistance for the aged (M.A.A.)
provision of the Kerr-Mills Act was intended to pro-
vide matching funds to purchase care for the medi-
cally needy — those persons who are unable to pay
for medical and hospital care needed to preserve
their health, but are able to otherwise provide for

their maintenance. Federal, state and county welfare
programs already provide for maintenance of and
medical care for the truly indigent.

The administration of the M.A.A. program in
California has permitted some of the funds allotted
to this program to be used to pay for certain medi-
cal care of welfare recipients that local government
was already obligated to provide. Some overlap-
ping is inevitable. The recipients of this care are
undoubtedly deserving, and in many instances, re-
ceiving quality care at less cost than was previously
available. However, since funds are needed to pro-
vide more professional and other services for those
intended to be benefited by the M.A.A. program,
the diversion of some of the funds intended for
this new group ought to be carefully reexamined.

The present program established by the Rattigan
Act made provision principally for financial help to
those with long-term chronic illnesses requiring hos-
pital and nursing home care. This was accomplished
by providing that “no cost of care shall be paid . . .
for the first 30 days of confinement in a hospital or
nursing home.”

Experience has shown that this 30-day exclusion
is grossly inequitable and does not provide for pay-
ment of care urgently needed in many cases.

First, the committee recommends that C.M.A.
urge support of an amendment to the Rattigan Act
which will provide a more realistic, flexible and
equitable initial exclusion or deductible. It might be
well to incorporate the concept of a certain dollar
amount or number of days’ confinement as a basic

VOL. 97. NO. 4 • OCTOBER 1962

243

deduction. Under regulations that might be adopted,
the maximum allowance for 30 days’ services to be
provided in a nursing home, may be set at a certain
figure such as $400. If a $400 deductible is proper
and equitable for a patient needing nursing home
care, it would seem appropriate that an equivalent
deductible in dollars be used for the patient who
needs hospitalization. In many cases, it is apparent
that excluding the cost of 30 days’ confinement in
a hospital is not promoting the true intent of the act.
In this regard also, it should be pointed out that the
program presently requires that once a person has
become eligible for M.A.A. benefits and then been
discharged from the hospital or nursing home, he
may not return to the same or similar facility and
be eligible for assistance without again accumulating
a 30-day commitment, unless his return to the hos-
pital is needed within 30 days of his discharge from
the hospital. This requirement does not promote
either good medical care or good public adminis-
tration.

The committee also feels that it is not medically,
socially or economically proper or necessary to re-
quire in all instances that eligibility be made pos-
sible only through hospitalization.

There are several ways in which needed flexibility
may be obtained. It is not deemed necessary to rec-
ommend one method over another.

Second, the committee recommends that one of
the conditions for determining the eligibility for
M.A.A. under the Rattigan Act be eliminated or
modified. Eligibility should be based more on medi-
cal care needs in comparison with income available,
without also considering certain arbitrary property
holdings.

The second of seven conditions of eligibility set
forth in Section 4701 of the Welfare & Institutions
Code reads: “Whose average monthly income over
the past 12 months is not expected to exceed the
costs of his medical care plus the cost of his main-
tenance as determined by the standards of assist-
ance for recipients of OAS.” This concept follows
the principle set forth in the Kerr-Mills Act. The
third condition set forth in Section 4701 of the
above code, reads: “Who does not own personal or
real property or both in excess of the amount per-
mitted for recipients of OAS.” Briefly, this require-
ment, among other things, limits personal property
holdings to $1,200. This means that one who is liv-
ing frugally off the income from a modest invest-
ment, worth say $15,000, must expend these reserves
before becoming eligible for financial aid in regard
to catastrophic medical care needs. This provision
makes it an advantage to own your own home but
not to have money in the bank. This limitation is
avoided by a few through certain sharp practices.

Physicians can often predict when certain illnesses

are going to be continuous and expensive and might
make eventual pauperization evident from the start.
In such cases, eligibility for financial assistance
should be expedited. There are several approaches
that can be developed so that worthy cases can be
handled equitably and some ultimate indemnity in
whole or in part be provided to the county in those
cases where a beneficiary leaves a substantial resid-
ual estate. Good medical care and sound public
policy would seem to be served if this existing con-
dition was modified or eliminated to permit discre-
tionary administration.

Third, the committee recommends that provision
be made for consecutive medical care payments in
any one month for those unusual cases where a per-
son is eligible for and needs assistance under both
the O.A.S. and M.A.A. programs. The present pro-
visions of the law make it impossible for such pay-
ments to be made separately and consecutively in
any one month. Since medical problems cannot be
handled wisely or economically on a calendar month
basis, a solution needs to be found for this problem
which was created by certain terminology in the
statutes.

Finally, the committee recommends that the Rat-
tigan Act and the public assistance medical care law
he amended to make possible improved statewide
financial administration of these programs at the
county level through California Physicians’ Service.
The state ought to be able to disperse state and fed-
eral funds directly to C.P.S., rather than dispersing
them to the county and having the county then pay
C.P.S. The county would continue to determine
eligibility, audit the funds, etc., but need not unneces-
sarily handle funds that will be distributed by C.P.S.

We must also continue to pledge the active,
prompt and realistic self-discipline of our own mem-
bership regarding the quality of services rendered
and charges made.

It may be anticipated that these suggestions may
occasion exaggerated estimates that such a program
will be too costly. These same voices loudly pro-
claim that all our aged people are entitled to medical
care, regardless of need. These critics are not inter-
ested in the cost of the program; they are only in-
terested in seeing to it that it is paid for by social
security taxes.

In general, it is respectfully suggested that basic-
ally, all of these recommendations provide for
greater flexibility and discretion on the part of the
welfare departments, both state and county, in order
to better provide for economic and quality care of
the medical needs of the aged.

Respectfully submitted,

William F. Quinn, M.D., Chairman
Liaison Committee to the State
Department of Social Welfare

244

CALIFORNIA MEDICINE

No. 12*

Parathion Poisoning— A New Antidote!

Physicians called upon to treat parathion and other phosphate ester poisoning
should be aware of the new antidote, 2-PAM, and its limited availability because of
its status as an investigational drug.

2-PAM (2-pyridinealdoxime methochloride) is available only as Protopam
chloride to physicians qualified in the clinical investigation of new drugs. They may
purchase it from Campbell Pharmaceuticals, 121 East 24th Street, New York 10.

2-PAM has been used most often and most effectively in the treatment of para-
thion poisoning. Physicians reporting upon its use in such cases have been enthusiastic
about its effectiveness and minimal side effects. Information is sparse regarding the
effectiveness of 2-PAM in the treatment of human poisoning from other phosphate
ester pesticides.

The present consensus is that 2-PAM and atropine are more effective together
than either alone. 2-PAM is a specific chemical antidote, releasing the cholinesterase
inactivated by the phosphate ester. However, it may not enter the central nervous
system in significant amounts, and atropine should always be given with 2-PAM to
combat the central effects.

Until 2-PAM is available on prescription, it is recommended that the limited
supply be used for serious poisoning which does not respond adequately to atropine.
Treatment for poisoning, including the use of 2-PAM when a qualified investigator
can administer it, or when it becomes generally available, is outlined as follows:

• Artificial Respiration, preferably by mechanical means, with administration
of oxygen and suction as indicated.

• Atropine. For severe poisoning, after cyanosis is overcome, inject intravenously
2 to 4 mg. (1/30 to 1/15 grain) every 5 to 10 minutes until signs of atropinization
appear. A total of 25 to 50 mg. may be necessary during the first day. For less severe
poisoning, inject 1 to 2 mg. (1/60 to 1/30 grain) and repeat each time symptoms
appear.

• 2-PAM. For severe poisoning in adults, inject 1 gm. slowly intravenously. Give
second dose of 500 mg. in about 30 minutes if muscle weakness is not relieved or
recurs. Doses for children should be in proportion to body weight.

• Decontaminate the skin, hair, eyes and stomach, as indicated. Remove clothing.

• Symptomatic treatment. Emergency lasts 24 to 48 hours and the patient must
be watched continuously.

• Cholinesterase test. Blood should be drawn for plasma and red cell cholinester-
ase test, preferably before 2-PAM is given.

• Contraindicated are morphine, aminophylline, theophylline, tranquilizers, large
amounts of fluids intravenously and possibly barbiturates.

• For further information, see “Organic Phosphorous Poisoning, and its Ther-
apy,” by W. F. Durham and W. J. Hayes, Jr., A.M.A. Archives of Environmental
Health, 5:21, July 1962.

Committee on Occupational Health
California Medical Association
Comments and Questions Are W elcomed by the Committee

"This is the twelfth of a series of articles prepared by the Committee on Occupational Health,

VOL. 97, NO. 4 • OCTOBER 1962

245

PUBLIC HEALTH REPORT

MALCOLM H. MERRILL, M.D., M.P.H.
Director. State Department of Public Health

Infectious hepatitis was reported with unprece-
dented frequency in 1961 both in California and in
the United States as a whole. Although the incidence
has dropped noticeably in 1962, this year appears
to be second only to last year, when 6,195 cases were
reported in the state.

Because of the mounting importance of hepatitis,
an intensive surveillance program was begun in the
spring of 1961 by the U. S. Public Health Service.
Study data in California were obtained from local
health departments.

The statewide attack rate based on reported cases
for the 52 weeks of the study was 35.3 per 100,000
persons, which is close to the national figure for that
interval. California’s highest attack rates occurred in
the mountain counties, although Merced County,
with one localized epidemic, had the highest rate of
any single jurisdiction. Moreover, 56.5 per cent of
the patients were 20 years of age and older.

This preponderance of cases in adults, which has
also been noted in certain eastern states, is not well
understood and was one of the observations that
prompted the study. No geographic pattern is evident
to suggest reasons for this high proportion of cases
in adults or the wide variations among jurisdictions.

Five factors were looked into. Previous hospitali-
zation was noted for less than eight per cent of the
cases, and in only three per cent had the patient been
in hospital two weeks to two months before onset.
Personal contact with a person who had infectious
hepatitis was recalled in over 30 per cent of the
histories, with family members accounting for al-
most half of these contacts. Contact history was more
frequent among the younger age groups.

Consumption of raw foods was an item of interest
because of the outbreaks elsewhere in the country
traced to contaminated clams and oysters. However,
less than 100 patients recalled eating raw clams or
oysters within eight weeks of the onset of disease,
and in some of these instances, the shellfish were of
eastern origin.

Consumption of other raw foods was so common
an event that no epidemiologic significance could be
ascribed to it. Water supply was identified as being
of community origin in about 90 per cent of the
histories, and in most of the remainder approved
private sources were used.

A history of blood or plasma transfusion or other
injection was obtained from about one-fourth of the
patients. In most of the more than 100 cases in
which the patient received transfusion, this proce-
dure was implicated in the subsequent hepatitis.

Although the study did not make provision for
recording fatal outcome, there were 36 histories
which included a note regarding the death of the
patient, indicating a case fatality rate of 0.8 per cent.

The present study, which continues and will soon
be improved by the inception of a revised history
form, has shown that a great deal of data can be
assembled on short notice in order to clarify the
growing public health problem of viral hepatitis.
The vital questions concerning the high incidence
of the disease, its unusual age distribution, and the
varied and perhaps unsuspected routes of spread
have not been answered with finality, but several
clues and new revenues of approach have been
suggested.

The local health officers and their staffs who con-
tributed energetically to this surveillance study merit
much praise and gratitude. The continuation and
refinement of this effort should help to bring under
control infectious hepatitis, a disease which is dis-
turbing in its elusiveness, frequency and morbidity.

i i 1

Controlled fluoridation of water supply of the city
of Gridley again demonstrates the effectiveness of
this economical public health measure in reducing
tooth decay.

Gridley’s children have 38 per cent fewer cavities
after only eight years of controlled fluoridation, and
in addition, one-third of them have no decay at all
in their permanent teeth. Eight years ago only 10
per cent of the children were decay-free. In 1956,
76 per cent of the children needed immediate dental
care for their permanent teeth. Now only 35 per
cent need immediate care.

i i i

The department’s fifth annual summer epidemi-
ology training program concluded in late August.
Thirty-eight medical students from 28 schools par-
ticipated this year. The trainees participated in 20
different research and field projects covering a wide
spectrum of public health activities in 12 bureaus
and laboratories.

246

CALIFORNIA MEDICINE

3ti Jttemortam

Caldwell. Geohce W., Azusa. Died September 6, 1962,
in Duarte, aged 59, of cardiac failure. Graduate of the Uni-
versity of Oregon Medical School, Portland, 1929. Licensed
in California in 1929. Doctor Caldwell was a member of the
Los Angeles County Medical Association.

Chhistopoulos, Basilios Konstantine, Oakland. Died
August 12, 1962, in Oakland, aged 64, of acute myocardial
infarction due to arteriosclerotic heart disease. Graduate of
National University of Athens School of Medicine, Greece,
1923. Licensed in California in 1929. Doctor Christopoulos
was a member of the Alameda-Contra Costa Medical Asso-
ciation.

Cornell, Harold Davis, Chula Vista. Died September 7,
1962, aged 78, of heart disease. Graduate of the University
of Michigan Medical School, Ann Arbor, 1910. Licensed in
California in 1920. Doctor Cornell was a retired member of
the San Diego County Medical Society and the California
Medical Association, and an associate member of the Amer-
ican Medical Association.

Ehrenclou, Olive Nisley, San Francisco. Died March
23, 1962, aged 68, of hypertensive cardiovascular disease.
Graduate of the University of California School of Medicine,
Berkeley-San Francisco, 1927. Licensed in California in
1931. Doctor Ehrenclou was a member of the San Francisco
Medical Society.

Hedge, Arden Russell, Monrovia. Died August 15, 1962,
in Los Angeles, aged 50, of heart disease. Graduate of Mc-
Gill University Faculty of Medicine, Montreal, Quebec,
1938. Licensed in California in 1939. Doctor Hedge was a
member of the Los Angeles County Medical Association.

Howard, Burt Foster, Sacramento. Died August 20,
1962, in Sacramento, aged 91. Graduate of Northwestern
University Medical School. Chicago, Illinois, 1899. Licensed
in California in 1909. Doctor Howard was a member of the
Sacramento County Medical Society, a life member of the
California Medical Association, and a member of the
American Medical Association.

Irvine, Robert Steele, San Carlos. Died August 14.
1962, in San Carlos, aged 78, of heart disease. Graduate of
Columbia University College of Physicians and Surgeons,
New York, N. Y., 1914. Licensed in California in 1917. Doc-
tor Irvine was a retired member of the San Francisco Med-
ical Society and the California Medical Association, and an
associate member of the American Medical Association.

Levisohn, Max, Fresno. Died August 23, 1962, in La-
guna Beach, aged 65. Graduate of Rheinische Friedrich-
Wilhelms-Universitat Medizinische Fakultat, Bonn, Prussia,

Germany, 1927. Licensed in California in 1941. Doctor Levi-
sohn was a member of the Fresno County Medical Society.

Newman, Harold, Chico. Died August 20, 1962, in Chico,
aged 49. Graduate of Northwestern University Medical
School, Chicago, Illinois, 1941. Licensed in California in
1945. Doctor Newman was a member of the Butte-Glenn
Medical Society.

Ostrander, Harold R., Covina. Died August 28, 1962, in
Covina, aged 52, of heart disease. Graduate of Rush Medi-
cal College, Chicago, Illinois, 1936. Licensed in California
in 1939. Doctor Ostrander was a member of the Los An-
geles County Medical Association.

Peters, Lindsay, Santa Barbara. Died August 3, 1962, in
Santa Barbara, aged 87. Graduate of the University of Vir-
ginia School of Medicine, Charlottesville, 1896. Licensed in
California in 1922. Doctor Peters was a member of the
Santa Barbara County Medical Society, a life member of
the California Medical Association, and a member of the
American Medical Association.

Schiff, Hans, Los Angeles. Died August 10, 1962, in
Carmel, aged 65, of heart disease. Graduate of Universitat
Kbln (Cologne) Medizinische Fakultat, Koln, Prussia, Ger-
many, 1920. Licensed in California in 1937. Doctor Schiff
was a member of the Los Angeles County Medical Asso-
ciation.

Schwarz, Alfred Joseph, San Anselmo. Died Septem-
ber 9, 1962, in Kentfield, aged 57. Graduate of St. Louis
University School of Medicine, Missouri, 1930. Licensed in
California in 1931. Doctor Schwarz was a member of the
Marin County Medical Society.

Swinney, Raymond Woolridge, Long Beach. Died Au-
gust 8, 1962, in Long Beach, aged 69, of myocarditis. Grad-
uate of the University of Kansas School of Medicine, Law-
rence-Kansas City, 1917. Licensed in California in 1929.
Doctor Swinney was a member of tbe Los Angeles County
Medical Association.

❖

Weinberc, Sydney L., Los Angeles. Died August 17,
1962, in Los Angeles, aged 62, of cerebral hemorrhage.
Graduate of the University of Michigan Medical School,
Ann Arbor, 1924. Licensed in California in 1925. Doctor
Weinberg was a member of the Los Angeles County Medi-
cal Association.

Wood, Avery Edwin, Watsonville. Died August 14, 1962,
near Half Moon Bay, aged 55. Graduate of the University
of California School of Medicine, Berkeley-San Francisco,
1935. Licensed in California in 1935. Doctor Wood was a
member of the Santa Cruz County Medical Society.

VOL. 97, NO. 4

OCTOBER 1962

247

iN'S AU

Afi

10 100 CALIFORNIA MEDICAL ASSOCIATION

Community Service

Service (servitium) — “Conduct contributing to the
advantage of another or others; as, a service to the
cause of freedom.” And what is the motivation for
rendering such service? Nothing other than a sense
of responsibility — without which one cannot be free
to serve.

Relating this to Community — -“A body of people
living in the same place under the same laws” — a
conscientious person can never escape responsibility
to some community, whether it be that of obedience
to the existing regulations, such as the antiditter
laws, or whether it be the kind one feels for his own
immediate community.

Doctors’ wives throughout our wonderful state are
serving their respective communities in a myriad of
ways — many through service projects activated by
their auxiliaries to the county medical societies.
Which of you, for instance, has not had his wife
mention hours of work connected with a health
agency, a poliomyelitis project, a blood bank, a
P.-T.A., a local church, a service organization, a
cultural, educational or civic project, a youth group,
or a hospital auxiliary?

The necessity for “The Public Be Served” theme
for this summer’s A.M.A. Institute has never been

more axiomatic. And so YOU and YOUR WIFE
must “Do, and exhibit your doing. Things do not
pass for what they are, but for what they seem: to
have worth, and to know how to show it, is to be
worth double; that which is not made apparent is
as though it were not, for even justice is not ven-
erated unless it carry the face of justice; those who
are fooled outnumber those who are not: for it is
sham that rules, and things are judged by what they
look, even though most things are far different from
what they appear; a good exterior is the best rec-
ommendation of the excellence of the interior.”*

In offering one’s self to “good works,” there should
be great discernment, however, for “Great coolness
is necessary with the drowning if you would bring
them help without peril to yourself.”* The creed,
then, or so it seems to your writer, should always
be that of involvement in those services which either
educate, give temporary assistance, or enrich the life
of the individual rather than those which sow the
seeds for permanent dependence.

Muriel F. Rumsey

Community Service Chairman
IF omans Auxiliary to the
California Medical Association

* Gracian’s Manual as translated from a 1653 Spanish text by
Martin Fischer.

YES on 22

248

CALIFORNIA MEDICINE

INFORMATION

The Financing and Provision of
Medical Care in California

A Report of the Bureau of Research and

Planning, California Medical Association

In the spring of 1961, the Bureau of Research and
Planning initiated a study of a group of miscel-
laneous plans in California through which medical
care is financed or provided to various segments
of the public. The study was stimulated by a desire
to acquaint the medical profession with some of the
mechanisms — other than those traditionally identi-
fied with voluntary health insurance, such as Blue
Cross, Blue Shield, and private insurance — through
which health services are purchased in the com-
munity by groups such as management, labor and
consumers. The emergence of increasing numbers
of health and welfare funds, self-insured funds, and
even physician-sponsored group practice and Foun-
dation prepayment plans reflects the diversity of
mechanisms for the provision and financing of
medical care.

Subsequent to the initiation of the study, the Cal-
ifornia Medical Association’s 1961 House of Dele-
gates adopted Resolution No. 85 which gave further
evidence of the interest of the medical profession
not only in the group of miscellaneous plans but in
all techniques employed by the public to avail itself
of voluntary health care services within the State.
The Bureau of Research and Planning, therefore,
decided to expand the scope of its inquiry and to
assemble within one document objective information
concerning as many varieties of techniques as could
be compiled with the assistance of the financing
mechanisms or providers of service.

The results of the study, scheduled for publication
in October,* should be of interest to physicians and
their organizations and to various segments of the
public. The purpose of this article is to direct atten-
tion to the report and to some of the findings which
appear to be of immediate interest.

The first few sections of the study discuss the role
of voluntary health insurance in the provision of
coverage for health care needs and its growth over

* Copies of the report, entitled A Study of the Financing and Pro-
vision of Medical Care in Calif ornia/ will be available at $2.00 each
from: Six Ninety Three Sutter Publications, Inc., 693 Sutter St., San
Francisco 2, California.

the past decade. These phenomena are viewed rela-
tive to the various groups and organizations which
have come under this system of health care protec-
tion. They denote the importance of groups covered
because of occupational affiliation, such as programs
negotiated by managment and unions and for Fed-
eral Government employees and State employees.
Affiliation, either through union membership or
employer participation, is one of the major reasons
for the growth in the total number of persons with
health insurance protection. Information on private
insurance, Blue Cross and Blue Shield (CPS) plans
in California place in proper perspective the detailed
descriptions of over 40 miscellaneous plans which
constitute the largest section of the study. These
plans assume importance in California because of
their wide variety, the method of organization and
operation, the types of services provided and the
participation of a significant number of physicians
in their programs. This study brings together for
the first time detailed descriptions not available
elsewhere in any single reference source.

The study of the structure and other characteris-
tics of such programs, other than private insurance,
Blue Cross and Blue Shield, is important in any
meaningful evaluation of the mechanisms through
which health care is received. California represents
one of the prime markets for health service due
to the size, composition and urbanization of its
population and its high level of disposable personal
income. In I960, of the almost 70 per cent of the
population in California covered by some type of
voluntary health insurance, 10 per cent received
their health service through the mechanism desig-
nated as miscellaneous plans. The variety of these
plans in existence indicates the degree to which
choice may be exercised when alternatives to the
more traditional types of plans are made available.
These alternatives are characterized by such eco-
nomic, social and political factors as comprehensive-
ness of coverage, premium cost, foreseeable out-of-
pocket expenses, programs developed along industry
lines (such as railroad plans), political sovereignty
(unions), social orientation (consumer and group
practice plans) and other social and economic de-
terminants.

Of the more than one million subscribers and
dependents provided with coverage under 44 mis-
cellaneous plans in 1960 (see Table 1), the larger
enrollment was for surgical and medical benefits.
The smaller enrollment for hospital benefits is due
to the number of persons with hospitalization cover-
age under a separate plan, either Blue Cross or
private insurance.

The size of the plans ranges from 150 to 400,000
persons. Approximately 50 per cent of the plans

VOL. 97, NO. 4 • OCTOBER 1962

249

range in size from 5,000 to 50,000; however, 80
per cent of the persons covered are to be found in
three plans with membership of over 100,000 each.
An important characteristic of these plans is the
large number which have incorporated the service
benefit principle. Of a total of 40 plans reporting,
75 per cent provide service benefits only; these
plans serve between 80 and 90 per cent of all per-
sons enrolled in Miscellaneous plans. If those plans
offering service benefits are combined with plans
offering a combination of service and indemnity
benefits, 95 per cent of all plans offer service bene-
fits to between 90 and 95 per cent of all members
enrolled in Miscellaneous plans. Table 2 classifies
the types of benefits by the 40 Miscellaneous plans
which reported such information.

The financing of medical care in the various
plans generally depends upon the composition of the
group procuring health services and the arrange-
ments made between purchasers and providers of
medical care.

The most common method by which these plans
are financed is through Health and Welfare Funds.
These funds collect monies, generally from the em-
ployer, to purchase a group of fringe benefits. Occa-
sionally, however, the employee also contributes to
the Fund. Among the group of 40 Miscellaneous
plans, 25 per cent are financed through Health and
Welfare Funds; over 20 per cent of these plans
are financed primarily by the individual member.
Table 3 designates the source of financing for health
care services.

The date of origin and sponsorship of the Mis-
cellaneous plans are indications of developments in
the demand for health care protection. (See Table
4. ) These data also reflect the role of plans spon-
sored by nationality groups in California to provide
protection to immigrants and whose origin dates
back over one hundred years. Other plans with a
long history of operation are those employer-spon-
sored plans found primarily in the Railroad, Utility,
and Oil Industries. Some of these employer-spon-
sored plans date back over 50 years with one orig-
inating in 1869. However, half of the 44 plans had
their origin after World War II when fringe benefits
assumed greater importance in collective bargain-
ing. Approximately 30 per cent of the Miscellaneous
plans began since 1955. Of those originating during
this period, 40 per cent were sponsored by unions,
23 per cent by medical groups, and the remaining
plans by consumer groups and employees.

Approximately 3,500 physicians participate part-
time or full-time in these various plans. These phy-
sicians represent 18 per cent of the total number
of physicians engaged in active practice in Califor-
nia as of December 1961. Many of these same phy-

TABLE 1. — Estimated Number of Persons Provided with Hospital,
Surgical and Medical Coverage in 44 Miscellaneous Plans in
California, December 7960*

Type of Benefit

Number

Hospital

Subscribers

Dependents

408,016

589,444

total

997,460

Surgical

Subscribers

Dependents

433,715

605,487

Total

1,039.202

Medical

Subscribers

Dependents

433,715

605,487

Total

1,039,202

* Enrollment data for most plans are as of December 31, I960.
However, some plans provided information for years ended in 1959
and 1961.

TABLE 2.— Type

of Benefit Coverage for 40 lOut
Miscellaneous Plans

of 441

Type of
Benefit*

Number
of Plans

Per Cent
of Total

Service only

Indemnity only

Service and indemnity

Service only and

Service and indemnity

Indemnity only and

Service and indemnity

* Indemnity benefit is one which provides reimbursement on the
basis of a schedule of benefits in partial payment for services ren-
dered. The terms "cash indemnity” or "fee-for-service” are often used
interchangeably with that of "indemnity benefit.”

Service benefit refers to payment in full for services rendered, as
provided for in a schedule of benefits which a physician agrees to
accept within the terms of or under the conditions specified in the
participation agreement. It is also applicable to those situations in
which direct service is provided by physicians serving on some sal-
aried or other contractual arrangement in group practice or closed
panel plans.

TABLE 3. — Source of Financing of 40 (Out of 441 Miscellaneous
Plans

Type of Financing

Number
of Plans

Per Cent
of Total

Employee

.... 5

12.5

Employer

... 1

2.5

Employee-Employer

.... 3

7.5

Health & Welfare Fund

... 10

25.0

Individual member

.... 9

22.0

Combination of above

.... 11

27.5

Other

.... 1

2.5

Total plans reporting

.... 40

100.0

sicians are also engaged

individual

or partnership

types of private practice.

large number of the

participating physicians

accept fees in full payment

for professional services

rendered.

However, the

most common remuneration

for services rendered

to participating physicians in group practice is a
salary. Salaried physicians include those physicians
who are paid on an hourly basis as well as physi-
cians who are members of medical groups.

250

CALIFORNIA MEDICINE

TABLE 4. — Sponsorship of 44 Miscellaneous Plans by Date of Origin

Plan Before 1900- 1930- 1940- 1945- 1950- 1955- 1960-

Sponsor 1900 1929 1939 1944 1949 1954 1959 1961 Total

Consumer .... 2 1 .... .... 1 .... 4

Employee .... .... 1 .... 1 1 •••■ 3

Employer 15 2 1 .... .... .... .... 9

Employee-Employer 1 1 .... .... .... .... .... 2

Fraternal 2 1 .... .... .... 1 .... .... 4

Medical Group 1 1 .... .... 112 6

Union .... .... .... 1 7 4 1 13

Other* 3

Total 3 8 6 3 1 10 10 3 44

'"Other" refers to several types of sponsorship.

The study also contains detailed descriptions of
the benefits provided by this group of plans. In
view of their wide diversity, this article attempts no
summarization, but merely notes their range in scope
from diagnostic and ambulatory out-patient care to
comprehensive in and out of hospital service2.

Also incorporated in the study are descriptions of
several student health services in California. These
plans were included for illustrative purposes only,
and serve as examples of arrangements that exist.
To a large extent, the professional services under
these programs have been rendered by groups con-
sisting of a limited number of physicians. Within
the last few years, however, many of these student
health service programs have begun to provide
coverage for the student and, in some cases, his
family, under California Physicians’ Service and
Blue Cross programs.

A significant development in the financing and
provision of medical care has been the introduction
of Foundation programs for medical care, sponsored
by medical societies to finance health services and
to assure the provision of good medical care to the
public. The rendition of good medical care is as-
sured through the use of review techniques by
physicians within the community. Two of the de-
scriptions included in the study — San Joaquin
Foundation for Medical Care and Riverside Usual
Fee Program — represent two concepts developed and
presently being implemented by county medical
societies.

At the beginning of 1962, Foundations for Medi-
cal Care were in operation in the following counties:
Alpine, Calaveras, Fresno, Kern. Kings, Mariposa,

Merced, Monterey, Orange, San Bernardino, San
Diego, San Joaquin, Santa Clara, Sonoma, Stanis-
laus, Tulare, and Tuolumne. Usual Fee Programs
have been established in Riverside and one is being
established in Marin.

Another group of counties employing the usual
fee concept but whose programs are limited to the
financing aspects of medical care are: Centinela
Valley (Los Angeles County), Imperial, San Luis
Obispo, and San Mateo, whose programs are under-
written by the California Physicians’ Service. The
Long Beach Physicians’ Health Plan is yet another
example of medical society sponsored programs
which employ the C.M.A.-R.V.S. with specifically
designated conversion factors underwritten by in-
surance companies and/or California Physicians’
Service.

The study includes an example of another type
of program. The Douglas Aircraft Company pro-
gram has been included to illustrate a plan which
incorporates some of the characteristics of a medical
society sponsored program, although it originated
with the employer and its insurance underwriter.
Its method of operation and enrollment of physi-
cians represent departures from the types of pro-
grams generally associated with private insurance
carriers.

The study arrives at no conclusions or recommen-
dations regarding the types of programs available to
the public. Its purpose is to contribute to a better
understanding of the financing mechanisms in exist-
ence in California and to serve as a basic reference
for those interested in this subject.

California Medical Association, 693 Sutter Street, San Francisco 2.

YES on 22

VOL. 97, NO. 4 • OCTOBER 1962

251

NEWS & NOTES

NATIONAL • STATE • COUNTY

ALAMEDA

Dr. Arnold Nurock has been named director of the Birth
Defects Center at Children’s Hospital of the East Bay. He
will head a team whose work will be carried on in the new
$900,000 William H. and Helen G. Ford Diagnostic and
Treatment Center at the hospital. Among its services the
team will perform diagnostic studies to determine if the
problems of patients referred to the center are due to birth
defects. If so, the team will work out a complete plan of
rehabilitation to enable the patient to function at the high-
est possible level. The causes of birth defects also will be
investigated.

GENERAL

California Physicians’ Service, participating in a cam-
paign by Blue Shield plans across the nation to enroll per-
sons over 65 years of age in prepaid health care coverage,
is offering to senior citizens in this state a comprehensive
scope of benefits including hospitalization, physician care
in a hospital, surgical treatment in hospital or office, x-ray
and laboratory services, inhospital psychiatric care and post-
hospital convalescent care.

The plan is being offered at $13.85 a month for indi-
viduals and C.P.S. member physicians will accept C.P.S.
fees, based on a $4 Relative Value factor, as payment in
full for covered physician services if the patient's income is
$6,000 a year or less. Enrollment in the new plan is not
subject to a physical examination or health statement,
and past or present state of health does not affect eligibility
for membership. November 15 has been set as the closing
date for enrollment.

California Physicians’ Service now provides coverage for
some 50,000 persons over 65.

The Audio-Digest Foundation, non-profit subsidiary of
the California Medical Association, is considering adding
articles on ophthalmology to its present group of tape
recordings that are offered for subscription by physicians.
Audio-Digest recordings over the past ten years have become
popular means of “keeping up” in six other areas of med-
ical practice: General practice, surgery, internal medicine,
obstetrics-gynecology, pediatrics and anesthesiology. More
than 30,000 recordings are mailed to all parts of the world
each month.

According to the Foundation’s board of trustees, the exact
commencement date of Audio-Digest Ophthalmology de-
pends upon how many pre-enrolled subscribers are obtained
between now and early 1963. It is intended that the tapes
will be issued twice each month. If sufficient interest is
indicated from otorhinolaryngologists, as well as ophthal-
mologists, one tape a month will be devoted solely to the
eye and the other to ear, nose, and throat.

Interested specialists are invited to indicate their sub-
scription choice by writing for further information from
C. L. Oakley, editor, 619 S. Westlake Ave., Los Angeles 57.
* ❖ ❖

Dr. Malcolm H. Merrill, California director of public
health, has been appointed by President John Kennedy to

serve on the newly formed national Health Resources
Advisory Committee.

The committee was created as a result of recommenda-
tions made by the Health Resources Management Confer-
ence, held in January. Its purpose will be to make recom-
mendations to the Director, Office of Emergency Planning,
on questions of policy relative to the production, allocation,
and utilization of health resources under various emergency
and mobilization situations.

* * *

Financial help in the care of children with cystic
fibrosis recently became available through the California
Crippled Children’s Service.

Physicians having patients with the disease who are in
need of such help may obtain information from the Crip-
pled Children’s Service or from the nearest local chapter of
the National Cystic Fibrosis Research Foundation. Both are
listed in telephone books under, respectively Crippled Chil-
dren and Cystic Fibrosis.

In calling attention to the new assistance program, the
San Francisco chapter of the Cystic Fibrosis Foundation
said that “the number of CF applications on file with each
county Crippled Children’s Service will play an important
part in helping this agency determine the amount of money
needed to finance the program during the next fiscal year.”
* ❖ ❖

Cooperating with the national Youth Fitness Program,
the School Health Committee of the C.M.A. has prepared
a guide for use by physicians concerned with developing
health education programs in schools of their own com-
munity.

Copies of the guides — two and a half pages of printed
matter — have been sent to component societies, which can
distribute them to interested physicians. In addition the
California Department of Education has mailed them to
1,400 school superintendents with a covering letter urging
close cooperation with local medical societies.

In a letter transmitting the guides to component societies,
Dr. Omer W. Wheeler, president of the California Medical
Association, and Dr. M. H. Jennison, chairman of the Com-
mittee on School Health, said:

“While schools are now emphasizing vigorous exercise,
the medical profession must be watchful that other aspects
of fitness are not neglected. Cooperation with school author-
ities at the local level to work out acceptable procedures for
periodic examinations, for screening procedures, and for
transmitting medical information to schools is necessary.
Cooperation is a joint responsibility of each Component
Medical Society School Health Committee and individual
physicians and the schools of each community.”

* * *

A five-day Postgraduate Course on the Modern Physio-
logical Concept of Cardiovascular Disease, directed by
Dr. Arthur Selzer, will be given by the American College of
Physicians February 11-15, 1963, at Presbyterian Medical
Center, San Francisco. The tentative program for the course
follows:

MONDAY, FEBRUARY 11

Morning Session — Chairman, Arthur Selzer, M.D.

8 :30-9 :30 — Registration.

9:30-10:15 — Lecture: Current Concepts of the Regulation
of Cardiac Performance, Stanley Sarnoff, M.D.

10 : 15-10:35 — Intermission.

10:35-11:00 — Physiological Basis of Dyspnea, Frederic El-
dridge, M.D.

11:00-11:30 — Origin of Heart Sounds, John J. Kelly, Jr.,
M.D.

11:30-12:15 — Panel: Cardiac Murmurs; Moderator: Arthur
Selzer, M.D.; Panelists: J. J. Kelly, Jr., M.D., David

252

CALIFORNIA MEDICINE

Bruns, M.D., Howard Burchell, M.D., and Herbert Hult-
gren, M.D.

Afternoon Session — Chairman, Forrest M. Willett, M.D.

Symposium: Applied Hemodynamics

1:30-2:05 — Cardiac Output, Arthur Selzer, M.D.

2:05-2:40 — Vascular Resistances: Systemic and Pulmonary
Hypertension, Malcolm Mcllroy, M.D.

2:40-3:10 — Arterial and Venous Pulses, Howard Burchell,
M.D.

3:10-3:30 — Intermission.

3:30-4:05 — Physiological Effects of Exercise Upon the Cir-
culation, Robert Bruce, M.D.

4:05-4:40 — Atrial Function, Stanley Sarnoff, M.D.

4:40-5:15 — Question and Answer Period.

TUESDAY, FEBRUARY 12

Morning Session — Chairman, Dwight L. Wilbur, M.D.

9:00-9:30 — Demonstration: Physiological Equipment.

9:30-10:15 — Lecture: Physiology and Pharmacology of the
Autonomic Nervous System, Julius Comroe, Jr., M.D.

10:15-10 :35 — Intermission.

10:35-11:05 — Renal Factors in Hypertension, Thomas Sta-
nley, M.D.

11:05-11:35 — Hemodynamics of Arterial Hypertension, Her-
bert Hultgren, M.D.

11:35-12:20 — Panel: Hypotensive Drugs; Moderator: Her-
bert Hultgren, M.D.; Panelists: Philip Pillsbury, M.D.,
Howard Burchell, M.D., David Rytand, M.D., and Fred-
erick Meyers, M.D.

Afternoon Session — Chairman, Leyland Stevens, M.D.

Symposium : Electrophysiology of the Heart

1:30-2:05 — Atrial Arrhythmias, David Rytand, M.D.

2:05-2:40 — Ventricular Arrhythmias, Herbert Hultgren,
M.D.

2:40-3:05 — Cardiac Response to Electrical Stimulation, John
Sampson, M.D.

3 :05-3 :25 — Intermission.

3:25-4:10 — Current Concepts of Ventricular Activation, Al-
len Seller, M.D.

4:10-4:45 — Orthogonal Lead Systems in Electrocardiogra-
phy, Mervin Goldman, M.D.

4:45-5:15 — Question and Answer Period.

WEDNESDAY. FEBRUARY 13

Morning Session — Chairman, Robert L. Smith, Jr., M.D.

9:00-9:30 — Demonstration: Physiological Equipment
(continued)

9:30-10:15 — Lecture: Current Concepts of Myocardial Me-
tabolism, Wilfred Mommaertz, M.D.

10 : 15-10 :35 — Intermission.

10:35-11:05 — Roentgen Physiology of the Coronary Circula-
tion, Herbert L. Abrams, M.D.

11:05-11:35 — Coronary Function Tests, Howard Burchell
M.D.

11:35-12:15 — Panel: Physiologic Aspects of Coronary Insuf-
ficiency; Moderator: Robert L. Smith, Jr., M.D.; Panel-
ists: Herbert L. Abrams, M.D., John Sampson, M.D., and
Howard Burchell, M.D.

Afternoon Session — Chairman, Harold K. Faber, M.D.

Symposium : Cardiac Failure

1:30-2:00 — Changing Concepts of Cardiac Failure, John
Osborn, M.D.

2:00-2:30 — Pathogenesis of Pulmonary Edema, Stanley Sar-
noff, M.D.

2:30-3:10 — Electrolyte Balance and Imbalance in Heart Fail-
ure, Isadore Edelmar), M.D.

3 : 10-3:30 — Intermission.

3:30-4:10 — Endocrine Factors in Cardiac Failure, John
Luetscher, M.D.

4:10-4:40 — Hemodynamics of Cardiac Failure, Arthur Sel-
zer, M.D.

4:40-5:15 — Question and Answer Period.

THURSDAY, FEBRUARY 14

Morning Session — Chairman, Edgar Wayburn, M.D.

9:00-9:30 — Demonstration: Extracorporeal Circulation.

9:30-10:15 — Lecture: Immunology and the Cardiovascular
System, Halsted Holman, M.D.

10:15-10 :35 — Intermission.

10:35-11:05 — Lipids and Coronary Disease, R. Gordon
Gould, M.D.

11:05-11:35 — Coagulation and Thrombosis and Cardiovascu-
lar Disease, Christian Borchgrevink, M.D.

11:35-12:15 — Panel: Arteriosclerosis: Moderator: Col. Loren
F. Parmley, M.C., U.S.A.; Panelists: Alvin Cox, M.D.,
R. Gordon Gould, Ph.D., C. Borchgrevink, M.D., Howard
Burchell, M.D.

Afternoon Session — Chairman, Emile Holman, M.D.

Symposium: Physiological Aspects of Operable Heart
Disease

1:30-2:05 — Hemodynamics of Valvular Stenosis, E. Wm.
Hancock, M.D.

2:05-2:40 — Hemodynamics of Valvular Regurgitation, Elliot
Rapaport, M.D.

2:40-3:25 — Physiological Consideration in the Surgical
Treatment of Congenital Heart Disease, Howard Burchell,
M.D.

3 :25-3 :45 — Intermission.

3:45-4:20 — Physiological Lessons from Cardiac Surgery,
Frank Gerbode, M.D.

4:20-4:45 — Regressive Physiological Changes following Car-
diac Surgery, Arthur Selzer, M.D.

4:45-5:15 — Question and Answer Period.

FRIDAY, FEBRUARY 15

Chairman, George Robson, M.D.

9:00-9:40 — Film: “Extracorporeal Circulation and Hypo-
thermia in Cardiac Surgery, Doctors Gerbode and Osborn.

9:40-10:10 — Perfusion and Hypothermia, John Osborn,
M.D.

10 : 10-10:30 — Intermission.

10:30-11:15 — Lecture: The Control of Peripheral Circula-
tion, Professor A. David M. Greenfield.

11:15-11:45 — Catecholamines and the Cardiovascular Sys-
tem, Alan Goldfien, M.D.

11:45-12:15 — Effect of Chronic Respiratory Diseases upon
the Circulation, Frederic Eldridge, M.D.

12:15-12:20 — Closing Remarks.

VOL. 97, NO. 4

OCTOBER 1962

253

MEDICAL PHARMACOLOGY — Principles and Concepts

— Andres Goth, M.D. , Professor of Pharmacology and
Chairman of the Department, University of Texas South-
western Medical School, Dallas. The C. V. Mosby Com-
pany, St. Louis, 1961. 551 pages, $11.00.

There is no question of the need for a really short text-
hook of pharmacology. The major texts are primarily useful
for reference, and are not ideally suited to the needs of
either medical students or most physicians. Some of the
English texts come close to meeting this need ( in my opin-
ion the best is Wilson and Schild's revision of A. J. Clark's
Applied Pharmacology ) , but perhaps due to differences in
nomenclature of the drugs they are not especially popular
in the United States.

Dr. Goth has attempted to provide the basic principles of
pharmacology in a volume of modest size. This book is a
valuable step in the right direction, even though the author
does not completely succeed in attaining his difficult objec-
tive. In the first place, the discussion of general principles,
such as drug absorption, metabolism, site of action, struc-
ture-activity relationships, mechanisms of action, drug reac-
tions and toxicity, is limited to an introductory chapter of
25 pages. While this might suffice for a physician whose pri-
mary interest is likely to be in the action of a specific drug,
it does not provide an adequate background for a student
attempting to gain a basic understanding of modern phar-
macology.

It is not surprising to find in a single-author text on a
broad subject some unevenness in tbe quality and compre-
hensiveness of coverage. There is a striking contrast between
the excellent and perhaps too-detailed chapters on histamine
and the antihistamines and the sketchy coverage of the sex
hormones, vitamins, and the pharmacologic basis of the
effects of drugs on the gastrointestinal tract. The author has
included a bibliography at the end of each chapter, usually
citing original articles or important reviews. This is a com-
mendable feature, since there is often a temptation to omit
bibliographic references in the shorter texts, thus discourag-
ing the student from seeking out further information.

The author devotes too much space in proportion to the
size of the book to the reproduction of structural formulas
of drugs. (I estimate that the equivalent of 50 pages is oc-
cupied by these formulas.) While a review of the chemistry
of drugs is certainly essential to an understanding of the
principles of drug action, the inclusion of many pages of
structural formulas without adequate discussion of the sig-
nificance of the chemical modifications within the various
groups of drugs appears to be an extravagant waste of
space. Moreover, a consistent method of rendering the
formulas has not been used; in some cases closely related
drugs are illustrated in a manner that would require the
non-chemically oriented student or physician to spend a
good deal of extra time ascertaining the structural rela-
tionships.

In a book designed for medical students or practicing
physicians, one would hope for a more extensive use of

carefully designed diagrams to illustrate the principles un-
der discussion. In a few instances these are effectively used,
but in many places discussions of rather complex phenomena
would have been aided by the judicious use of diagram-
matic illustrations.

The occasional use of trade names and the use of charts
or graphs which refer to agents no longer in active use can
probably be pardoned on the basis of the fallibility of a
single author. Misprints are few, and save for an occa-
sional minor error in structural formulas, are not distracting.
The book is well indexed, well printed, attractive, and easy
to read.

In spite of the defects mentioned above, the book has
many good points. It is of readable size; the author’s style
is clear and concise. It is a tribute to Dr. Goth’s knowledge
and experience in teaching that he has been able to cover
such a broad field so effectively. This book might well be
recommended for medical students in a second year phar-
macology course, although my personal preference would
be to encourage students to become somewhat familiar with
one of the more detailed and definitive texts which can
serve as a reference volume in later years. For the practic-
ing physician who wishes a reasonably brief review of mod-
ern pharmacology, Goth’s book comes closer to meeting the
need than any other available text.

Peter V. Lee, M.D.

MARTINI’S PRINCIPLES AND PRACTICE OF PHYSI-
CAL DIAGNOSIS — Third Edition — Revised by Yale Knee-
land, Jr., M.D. , Professor of Medicine, Columbia Univer-
sity; Attending Physician, Presbyterian Hospital, New
York City; and Robert F. Loeb, M.D., Bard Professor of
Medicine, Emeritus, Columbia University; Consultant,
Presbyterian Hospital, New York City. J. B. Lippincott
Company, East Washington Square, Philadelphia 5, Pa.,
1962. 275 pages, $4.75.

This small book covers in very adequate fashion the sub-
ject matter indicated in the title. It also adheres closely to
the principles of Physical Diagnosis and purposely avoids
detailed consideration of roentgenography, electrocardiog-
raphy, and other specialized diagnostic technics.

The first section deals with the general examination and
emphasizes the importance of seeing, hearing, and feeling
in diagnosis and the necessity on the part of the examiner
to develop these faculties to a high degree.

The second section deals with more specific details and
the examination of the various body systems. Pertinent
physical findings are interpreted in the light of present
patho-physiological knowledge. There is little or no re-
dundant material presented.

This book was originally intended for tbe student to
guide him in his approach to the patient and his clinical
problems. This goal I believe has been successfully attained.

Clayton D. Mote, M.D.

254

CALIFORNIA MEDICINE

ACQUIRED SURGICAL LESIONS OF THE ESOPHA-
GUS— Clifford F. Storey, M.D. Charles C. Thomas, Pub-
lisher, 301-327 East Lawrence Avenue, Springfield, Illinois,
19G2. 365 pages, $19.00.

This is another monograph in the diaries C. Thomas
series. The purpose of the hook was to enlighten physicians
generally about disorders of the esophagus which are now
amenable to satisfactory treatment, surgical and otherwise.
It is designed to contribute to an earlier and more accurate
diagnosis of esophageal disease, and point out the available
methods of therapy in dealing with these disorders.

The subjects covered include achalasia, esophageal diver-
ticula, hiatus hernia, reflex esophagitis, ulcers and strictures
of the esophagus, foreign bodies of the esophagus, perfora-
tions, spontaneous and traumatic, and acquired esophageal
tracheobronchial fistula, as well as a discussion of tumors,
cysts and carcinomas of the esophagus. Esophageal varices
are also discussed adequately, including the available forms
of therapy.

On the whole, the book is an excellent review of these
acquired surgical lesions of the esophagus. It is well illus-
trated, the reference lists are complete and adequate. One
need hardly refer to the references, for the general material
contained within the book is adequate for all practical pur-
poses. I was a little disappointed in the illustrations of sur-
gical techniques, but the illustrations are very simply done
and are diagrammatic rather than elaborate. They are help-
ful but would not be sufficient to permit the uninformed
surgeon to completely orient himself with respect to the
operative procedure under discussion. The x-rays and illus-
trations are adequate and informative.

This book can be recommended as a concise, informative
and well-written book on acquired surgical lesions of the
esophagus.

Victor Richards, M.D.

* $ *

SHOCK-PATHOGENESIS AND THERAPY— An Inter-
national Symposium sponsored in Stockholm, 27th-£0th
June, 1961, by Cl BA. U. S. von Euler, Stockholm. Chair-
man; edited by K. D. Bock, Basle. Springer-Verlag,
Berlin, Gottingen, Heidelberg, 1962. Copies are available
from Academic Press in New York City at $13.00 each.

The four-day symposium of 41 participants from 14
countries was planned by von Euler. It included 31 papers,
which were followed by enthusiastic discussions. Together,
these reports present an extensive review of current re-
search on problems of shock. The index is comprehensive.
Extensive bibliographies omit the titles of references cited.
Important contributions include papers on metabolism dur-
ing shock by Mingone, irreversible shock in dogs by R.
Lillihei, classification of hypotensive states by Rushmer,
kidney function in shock by Kramer and by Selkurt, neural
factors by Neil, and the problems of experimental design
by Fine. A prospectus for future bedside research is pre-
sented (p. 269). A short section devoted to research on
therapy includes discussion of hypothermia, of fluid therapy,
and of drug therapy.

Rational therapy of the hypotensive state demands con-
cise definition of etiology and of the resulting chemical and
physiologic changes. Approximately eleven pathogenic mech-
anisms are distinguishable, and shock in turn may lead to
diverse terminal events. The common experimental models
are hemorrhagic shock and endotoxin shock. A major re-
search objective is to describe the mechanisms of irreversi-
ble shock.

Modern methods of measurement and control of blood
volume are replacing inadequate estimation techniques
based on the hematocrit and clinical signs, but do not
obviate the need for experienced judgment by the physician.

Vasoconstrictor drugs commonly prescribed may sometimes
be contraindicated, since excessive vasoconstriction can
alone induce shock, and milder adrenergic vasoconstriction
may accentuate development of traumatic or endotoxin
shock. Drug blockade of adrenergic vasoconstriction may be
beneficial in certain patients responding poorly to volume
replacement.

This scholarly symposium report is a valuable source-
book for experimental surgeons and clinical investigators,
and provides stimulating new views for cardiologist and

surgeon- Alfred W. Childs, M.D.

* * *

ELECTROCARDIOGRAPHY— Third Edition— E. Grey

Dimond, M.D., Director, Institute for Cardiopulmonary
Diseases, Scripps Clinic and Research Foundation, La
Jolla, California; Paul Schlesinger, M.D., Chief, Outpa-
tient Department of Cardiology, Fifth Medical Clinic, Uni-
versity of Brasil, Rio de Janeiro, Brasil; and Rafael L.
Luna, M.D., Cardiologist, Hospital Do Servidor Da Guana-
bara, Rio de Janeiro, Brasil. Distributor, The Corinth
Press, Box 51, Mission, Kansas, 1961. 196 pages, $6.00 per
copy.

This monograph, a third edition by Dr. E. Gray Dimond,
an outstanding teacher of electrocardiography, is a well writ-
ten and bold attempt to take tbe uninformed student or
practicing physician from a beginner’s level to an under-
standing of spatial electrocardiography and vectorcardiog-
raphy. He and his co-authors are clear, concise and direct
in their endeavor to develop a critical analysis of clinical
problems by means of these laboratory techniques.

The first section of 59 pages deals with the basic physi-
ology of vectors, leads and spatial analysis. Without present-
ing new or startling concepts, the authors develop succinctly
vector analysis; their text clearly reflects their experience
in participative teaching. The presentation of vector loops
by means of the cube system should not incur disfavor from
workers who advocate the Frank or other vector systems.

The second section of 27 pages discusses electrocardio-
graphic and vectorcardiographic alterations secondary to
ischemia, injury, necrosis, hypertrophy and block. Because
two of the authors are champions of the Mexican school of
electrocardiography, this section is slanted towards the
concept of systolic and diastolic overloading of the right
and left ventricles. Although this postulate is not univer-
sally accepted, it is an attractive way of trying to correlate
clinical with physiological data.

Section III, consisting of 54 pages, offers a series of 27
actual electrocardiograms and vectorcardiograms with de-
tailed analyses. Here is the meat of their work, offering a
unique opportunity to solve clinical problems. If there is a
chief criticism of the book, it is that the illustrations should
have been placed such that no reference would have been
necessary to a text on the back side of the illustrated pages.
One suspects that problems of cost prevented illustrations
and text being on single or adjoining pages, which would
have maintained more effective teaching and learning.

The final section of 43 pages is an alphabetical glossary
which defines more than 200 terms ranging from aberrant
conduction to the Wenckebach’s-Lucciani phenomenon. Per-
tinent bibliography is incorporated in the text.

Although several of the electrocardiographic reproduc-
tions could be enlarged for purposes of clarity, the vector-
cardiographic reproductions are quite satisfactory, and are
enhanced by the simultaneous illustration of body contour
diagrams with the vector loops.

This book throws light on a difficult problem, making it
valuable reading for the undergraduate or post-doctoral stu-
dent or physician who is not reading electrocardiograms or
vectocardiogams, as well as for those who are.

Hilliard J. Katz, M.D.

VOL. 97, NO. 4 • OCTOBER 1962

255

RENAL BIOPSY — Clinical and Pathological Significance
— Ciba Foundation Symposium— G. E. W. Wolstenholme,
O.B.E., M.A., M.B., M.R.C.P., and Margaret P. Cameron,
M.A., Editors for the Ciba Foundation. Little, Brown and
Company, 34 Beacon Street, Boston, Mass. 395 pages,
$10.50.

In this symposium 29 pathologists and clinical investi-
gators present papers and discuss at length what they have
learned from a total experience of over 5,000 renal biopsies.
The 13 papers deal electively with areas of active interest
in renal pathology. Most of their contents having been pub-
lished elsewhere, the papers serve as starting points for
lively workshop discussions, and this is where most of the
“pearls” can be found. The book is generously illustrated
with black-and-white photomicrographs, and the index is
very good.

Renal biopsy with its related techniques, electromicros-
copy and enzyme studies, has expanded our basic knowl-
edge and is raising the level of sophistication in the diag-
nosis of renal disease. Because of the extremely limited
amount of tissue that can be so magnified (it takes one
month of work to cover one square millimeter) electron
microscopy will remain a research tool. Its value lies in
teaching us to interpret light microscopy more accurately.

The disease most actively investigated has been the ne-
phrotic syndrome which can be associated with a great
variety of glomerular diseases. The clinical syndrome has
been likened to congestive heart failure in relation to heart
disease. In this area, the biopsy experience has established
a trend to replace the term “chronic glomerulonephritis”
with purely descriptive histological diagnoses: No glomeru-
lar disease by light microscopy but foot process fusion by
electronmicroscopy (synonym: lipoid nephrosis), prolifera-
tive glomerulonephritis, membranous glomerulonephritis.
This is advantageous since it avoids the implication of a
single etiology, poststreptococcal, for which there is no
support. There also is some correlation between morphology
and response to steroid treatment. Much work remains to
be done to establish whether the various morphological
types represent different entities, and which of them can be
stages of the same disease. In quite a few patients with a
wide variety of clinical presentations diseased glomeruli
may coexist with normal ones: focal glomerulonephritis.

In pyelonephritis, correct classification continues to re-
quire considerable judgment. To start with, no single patho-
logical feature of this disease is pathognomonic, perhaps
with the exception of cell casts which are not common. In
early pyelonephritis, the needle may miss the diseased
areas; later, renal biopsy will always be representative but
the degree of activity remains hard to judge. Cultures from
the renal tissue quite frequently will show organisms dif-
ferent from those found in the urine. Pyelonephritis can
present as acute anuria in which case the prognosis with
dialysis is good, it can present as recurrent isolated gross
hematuria, and it can occur with no proteinuria at all.
Finally, it does not appear to be a common concomitant of
the living diabetic.

There is fair agreement among these experts as to the
major clinical indications of renal biopsy: choice of treat-
ment in the nephrotic syndrome, acute anuria of obscure
etiology, apparent chronic nephritis or persistent proteinuria,
recurrent hematuria, choice of treatment in chronic infec-
tion. Injurious results have been exceedingly rare in the
hands of responsible investigators but widespread use of
this method is not advocated for reasons stated quite simply
by the initiator of renal biopsy, Dr. Poul Iversen: “The
renal biopsy technique and the judgment of the pathoana-
tomical changes are so difficult that the procedure and the
judgment should only go on at places where there is expert
knowledge.”

In the opinion of the reviewer this statement applies to
the readership this little book ought to reach: It is a must
for all those pathologists and internists aspiring to expertise
in interpreting renal biopsies if only to preserve their
humility in the face of many unresolved questions. It is not
recommended to the uninitiated since the amount of detail
presented would tend to overwhelm him.

K. Peter Poirier, M.D.

* * *

CLINICAL OBSTETRICS AND GYNECOLOGY— March
1962 — A Quarterly Book Series — Volume 5, Number 1 — The
Newborn — Edited by Michael Newton, M.D., and Office
Gynecology, Edited by Roger B. Scott, M.D. Published by
Hoeber Medical Division of Harper & Brothers, 49 East
33rd Street, New York 16, N. Y., 1962. The series is pub-
lished quarterly, $18.00 a year (sold by subscription only).
320 pages.

The “Yellow Quarterly” is a journal in book form, which
from its inception in 1958, has sought to provide a continu-
ing source of authoritative information in the various phases
of obstetrics and gynecology. Readers interested in either
the newborn or in gynecology will find this a worthwhile
volume containing a number of instructive contributions.

The first symposium in this issue commences with an
authoritative summary by Burnard on current concepts of
the newborn respiratory and cardiovascular physiology. An
otherwise excellent presentation of the immediate care of the
newborn is hampered by an inadequate discussion of resus-
citation; although the author notes that this was the subject
of a symposium which appeared two years previously. Chap-
ters on hyperbilirubinemia, the respiratory-distress syn-
drome, infant feeding, perinatal mortality and the problem
of staphylococcal disease are up-to-date, with current bib-
liographical references, and reflect current interest in these
subjects. The reader is admonished not to miss the fasci-
nating account by Jelliffe of the management of pregnancy,
labor and the newborn among primitive peoples in the “un-
derdeveloped” areas of the world. Jelliffe astutely appraises
the effects of some of these practices on maternal welfare
and child health. It is unfortunate that in this symposium a
chapter could not have been devoted to the fetal hazards
of maternally administered drugs, and of the relation of
maternal to fetal disease.

The second symposium in this volume considers the diag-
nostic and therapeutic procedures which can be conducted
in the gynecologist’s office. The importance of cancer detec-
tion is evidenced by six articles on this subject, ranging
from cytology and the pathologist; cytology and the clini-
cian, cancer detection, Moore’s article on cervical lesion,
an essay on vulvar lesions by Woodruff, and Faulkner’s pithy
article on adnexal enlargement. The reader will be delighted
with Dr. Henriksen’s account of the “Witch Syndrome,”
premenstrual tension. Other chapters include discussion of
the fern and Rubin test, pelvic and urinary tract infection,
geriatric gynecology, and problems in the management of
psychiatric illness. The subjects of infertility, dysfunctional
uterine bleeding, hormonal therapy, leucorrhea and stress
incontinence are regretfully not to be found in this presen-
tation. The editor notes, however, that some of these topics
have been covered in other recent symposia.

There are a few minor criticisms of this issue which in
no way detract from its overall value. In several cases
authors (e.g., Silverman) are referred to in the text without
a bibliographic reference. A few of the photographs, as
those on pp. 31, 34, 37 seem superfluous.

This symposium, however, well fulfills its purpose of pro-
viding for all interested in obstetrics and gynecology, a val-
uable source of authoritative information.

Lawrence D. Lonco, M.D.

256

CALIFORNIA MEDICINE

New Drug Termed Promising
Against Resistant Germs

A “promising new antibiotic” has produced good
results in patients with infections resistant to peni-
cillin, it was reported in the September 1 Journal
of the American Medical Association.

The drug, generically termed oxacillin, was de-
signed to fight penicillin-resistant strains of staphylo-
cocci. bacteria which present a thorny medical prob-
lem because of their prevalence and increasing re-
sistance to other antibiotics.

Studies have shown that strains of staphylococci
are resistant because they produce penicillinase, the
biologic antagonist of penicillin.

Oxacillin is a synthetic penicillin which resists
destruction by penicillinase, William M. M. Kirby,
M.D., Lona S. Rosenfeld, M.D., and Jean Brodie,
B.S., department of medicine, University of Wash-
ington School of Medicine, Seattle, wrote in the
Journal.

On the basis of laboratory tests and a study of
68 patients, the researchers concluded that oxacillin
is a potent and effective drug when administered
orally for the treatment of penicillin-resistant in-
fections. Side effects were minimal, they said.

Good results were obtained in 61 of the 68 pa-
tients and rated indeterminate in the other seven,
the researchers reported.

At the time treatment with oxacillin was started,
18 patients were considered seriously ill, they said,
and in each of these “there seemed a clear-cut
response to the antibiotic, and the patient was
cured.” The seriously ill included six patients with
pneumonia, five with severe head and neck infec-
tions, and three with infected burns, they said.

In laboratory tests, oxacillin was compared with
th ree other synthetic penicillins and found to be five
to eight times more active than one of them (methi-
cillin), against penicillin-resistant staphylococci, the
authors said.

“It is apparent from these observations that oxa-
cillin represents an important advance in the therapy
of infections caused by penicillinase-producing
staphylococci,” they said.

Thalidomide and Malformations in Liverpool — R. W.

Smithells, Lancet, 1:1270 (June 16) 1962.

An investigation was made into drugs taken during the
first trimester by the mothers of 30 babies with ectromelia,
22 with minor limb deficiencies, 7 with microtia and 40 nor-
mal babies. Thalidomide had been taken by 12, 2, 3, and 0
respectively.

* * *

Summer Outbreak of Influenza Type-B — J. R. L. Forsyth,

Lancet, 1:1400 (June 30) 1962.

Two summer outbreaks of influenza type-B differed from
the subsequent winter epidemic by the difficulty of isolating
the virus and the localization of spread in summer. These
differences could reflect changes in the host population
or in virus viability.

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Root, H. F.; White, P., and Marble, A.: ibid., pp. 188-189. (3) Marks, H. H„ et at.: Diabetes 9:500, 1960.
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Test Shows Whether Pain
Is Psychic or Physical

A test that can show whether pain is physical or
psychosomatic was described today by Dr. Leo
Alexander, a Boston psychiatrist.

The test is based on the patient’s psychogalvanic
reflex, a drop in the electrical resistance of the skin
in response to physical pain or mental challenge,
according to a report by Dr. Alexander in the Sep-
tember 8 Journal of the American Medical Asso-
ciation.

The psychogalvanic reflex is one of the impulses
recorded in lie detector tests.

Through tests of various psychiatric patients, Dr.
Alexander said, it had been noted that the galvanic
skin responses of patients suffering physical pain
were “strikingly different” from those suffering
from psychogenic pain when the natural fluctua-
tions were compared with those evoked by delib-
erate painful stimulation.

To test the validity of this observation, he stud-
ied 20 patients whose chief complaint was pain
which could be diagnosed definitely as either physi-
cal or psychogenic and, for comparison, an addi-
tional 14 patients who were free from pain.

Patients with psychogenic pain were found to
have a low rate of natural fluctuations of skin re-
sistance as well as a low level of responses to de-
liberate stimulation, Dr. Alexander said.

This suggests that psychogenic pain may repre-
sent a state to which the nervous system has become
conditioned and that, like depression, it may repre-
sent an inhibitory state, he said. Spontaneous and
evoked psychogalvanic responses have also been
found to be greatly reduced in Yoga trance states,
he said.

Patients who suffered physical pain showed
marked spontaneous fluctuations of skin resistance
that corresponded to the waxing and waning of the
physical pain while responses to induced stimulation
were uninhibited, he said.

This suggests that physical pain impinges upon
the nervous system in a manner comparable to that
of any other external stimulus or one to which the
system is not conditioned, he said.

However, another explanation may he that physi-
cal pain states tend to be intermittent and varying,
hence evoking apparently spontaneous psychogal-
vanic responses, while psychogenic pain states tend
to be continuous and unvarying, hence evoking less
frequent and less marked psychogalvanic responses,
he said.

The natural fluctuations of skin resistance among
pain-free patients did not differ from the psycho-
genic pain group but was significantly different
from the organic pain group, Dr. Alexander said.

Of the 12 patients suffering psychogenic pain, he
said, all but one responded to therapy.

(Continued on Page 70)

MORE URINE

INCREASED WEIGHT LOSS

Naturetin has greater diuretic action1'3 than either chlorothiazide or
hydrochlorothiazide. A trial with Naturetin demonstrates the increased
urine volume and the greater weight loss it provides.

1. Ford, R. V.: Clin. Res. Notes 2:1 (Dec.) 1959. 2. Ford, R. V.: Cur. Therap. Res. 2:92 (Mar.) 1960.
3. Elliott, J. P., Jr., and Goldman, A. M.: South. M.J. 54:794 (July) 1961.

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Salt-Water Retention Seen As
Clue to Obesity Control

The body’s retention of salt and water during a
weight reduction program “may be the greatest
single cause of failure in the treatment of obesity,”
Dr. S. K. Fineberg, New York City, said.

Ten to 20 pounds of water may be retained before
there is any apparent sign of edema, medical term
for the condition. Dr. Fineberg said in the Septem-
ber 8 Journal of the American Medical Association.

“After several weeks or months of fat loss, if
water retention occurs, the scale-weight loss stops
or even reverses, despite the patient’s adherence to
the same caloric intake and actual loss of fat tissue ,”
he said. “The perplexed patient assumes that he
cannot reduce his weight further and soon aban-
dons treatment.”

Apparently, he said, the incidence and severity
of water retention is far greater in women.

“This fact may help to explain the higher suc-
cess rates consistently found in men,” he said. “In-
deed, the patient’s sex has been quoted as the only
criterion which might aid in predicting the outcome
of attempts at weight reduction.”

Dr. Fineberg drew his conclusions from a study
of the treatment of 36 overweight diabetics at a
special clinic. The patients were all 50 to 100 per
cent overweight and were seen at the clinic once a
month for periods of six months to one year, he
said.

At the end of the year, 23 of the 36 patients had
lost an average of about 22 pounds during an av-
erage of nine and one-half months, he said. Fifteen
patients were able to discontinue specific drugs for
diabetes entirely, he said.

“The rate of success attained in this clinic, almost
80 per cent at the end of the first year, is remark-
ably high,” Dr. Fineberg said.

“The reasons for the almost unprecedented suc-
cess rate obtained are believed to be better motiva-
tion, less psychological obesity in diabetics, and im-
proved technique in using anorexigenic [appetite
suppressing] agents, but, most important, the detec-
tion and correction of water retention in more than
one-half of the patients. This well-known phenome-
non of unexplained origin has not heretofore been
documented as occurring with such persistence and
high incidence.

“The experience in this clinic suggests that onset
of prolonged salt and water retention during weight
reduction may be the greatest single cause of failure
in treatment of obesity.”

Dr. Fineberg is attending physician and chief of
the metabolism service and diabetes outpatient de-
partment, Harlem Hospital.

“The Twist” Fracture Dislocation of Patella — D. G.

Millard and T. H. Lee, N.E.J.M., 267:246 (Aug. 2) 1962.

A fracture dislocation of the patella has been observed in
a young woman during the performance of “The Twist,” an
energetic, torso-contorting dance.

LESS BICARBONATE LOSS

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1. Cohen, B. M.: M. Times 88:855 (July) 1960. 2. Cohen, B. M.: Med. et Hyg. (Geneve) #494, p. 210
(Mar. 15) 1961.

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Acute or chronic dermatitis

Chymoral

subdues inflammation and edema in acute or chronic dermatoses1,2

Chymoral may be employed to excellent advantage
for control of the inflamed and weeping lesions of
acute dermatoses, as well as for subacute and
chronic conditions. Used either as the sole agent or
as an adjunctto standard topical and systemic thera-
pies, Chymoral modifies inflammatory reaction,
helps improve regional blood flow, and dissipates
edema. It may therefore assist the skin’s own re-
parative attempts in such conditions as acne, ulcera-
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burns, and acute eczema or chronic atopic dermatitis.

1. Clinical Reports to the Medical Director, Armour Pharmaceutical Company,
1960. 2. Teitel, L. H., et a!.: Indust. Med. 29:150, 1960.

CHYMORAL

Chymoral is an ORAL anti-inflammatory enzyme tablet spe-
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one. ACTION: Reduces inflammation of all types; reduces and
prevents edema except that of cardiac or renal origin; hastens
absorption of blood and lymph extravasates; helps to liquefy
thick tenacious mucous secretions; improves regional circula-
tion; promotes healing; reduces pain. INDICATIONS: Chymoral
is indicated in respiratory conditions such as asthma, bron-
chitis, rhinitis, sinusitis; in accidental trauma to speed absorp-
tion of hematoma, bruises, and contusions; in inflammatory
dermatoses to ameliorate acute inflammation in conjunction
with standard therapies; in gynecologic conditions such as
pelvic inflammatory disease and mastitis; in obstetrics as
episiotomies and breast engorgement; in surgical procedures
as biopsies, hernia repairs, hemorrhoidectomies, mammec-
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orders as epididymitis, orchitis and prostatitis; in dental and
oral surgery as fractures of the mandible or maxilla, difficult
or multiple extractions, and alveolectomies. CONTRAINDICA-
TIONS: None known. INCOMPATIBILITIES: None known
Antibiotics as well as generally accepted measures may be
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OCTOBER 1962

Birth Records Should Indicate
Congenital Limb Deformities

Birth certificates should indicate the presence of
congenital limb deformities to facilitate research
into their cause and frequency, according to three
child amputee experts.

Prevention of disease in general and of malforma-
tions in particular requires detection of the causes,
and finding the causes often depends on accurate
knowledge of their frequency, according to Cameron
B. Hall, M.D., Milo B. Brooks, M.D., and Jeannine
F. Dennis, O.T.R., Child Amputee Prosthetics Proj-
ect, University of California, Los Angeles.

The frequency of congenital limb deficiency is
unknown, they said in an article in the August 18
Journal of the American Medical Association. Pres-
ent birth certificates do not provide for the recording
of such information and it has been included in
only a few medical centers, they said.

A method for classifying congenital limb deficien-
cies, developed by Dr. Ronan O’Rahilly of Wayne
University School of Medicine, provides a simple
description of seemingly complex and unrelated
malformations and should be used in initial birth
records, the author said.

Until the rate of occurrence is known, they said,
the role of the many factors implicated in these
deformities, such as heredity, diet, irradiation, hor-
mones, chemicals and injuries, cannot be evaluated.

The identification of environmental factors con-
tributing to congenital malformation ranks as one
of the areas most deserving of research, they said.

Hair Spray Toxicity
Questioned in J.A.M.A.

Reports suggesting that the inhalation of hair
sprays can cause a new lung disease were questioned
in the August 18 Journal of the American Medical
Association.

Thesaurosis, the term used to describe the ex-
cessive retention of certain chemical elements in
the lungs, has been attributed to heavy exposure to
hair spray, according to Dr. G. W. H. Schepers,
Wilmington, Del.

However, he said, there are “many points of sim-
ilarity” between thesaurosis and pulmonary sar-
coidosis, a chronic infectious disease affecting the
lungs.

Sarcoidosis is “a great imitator of many diseases,”
Dr. Schepers said, adding:

“It has been misdiagnosed before and probably
will continue to confuse issues in the future.”

Sarcoidosis is quite prevalent in the United States,
he said, and its manifestations in the lungs are often
transient and occur with marked prevalence in
women in their 30s and 40s.

“On a statistical basis alone, it seems not un-
( Continued on Page 78)

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'eC°\o''en ^ed0'^00' >-w'96'

tOer> , ,vHe< ^ j . (6e<J

30'

fv)f

Tim®5,

odd'"'

Promotes

Aciduric

Intestinal

Flora”

Stools became soft in an
Patients, and, within one week
bowel evacuations were accom-
plished with ease. Most patients
iked the taste of the product, and
the maionty of them reported a
feeling of well-being ”

Hootnick, H. J.: J. Am. Ger Soc
4:1021 -1030, 1956

Mes*e<°C,\

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Chicago 12, Illinois

X-Ray Treatment for Asthma
Has No Scientific Basis

Any claim that asthma can be permanently cured
by x-ray treatment or any presently known method
is without scientific foundation, Dr. Jerome Glaser,
Rochester, N. Y., a pediatric allergist, said in the
September 1 Journal of the American Medical
Association.

A recently publicized technique is purported to
benefit asthma sufferers “by x-ray treatment of in-
fected lymphoid tissue in the sinus cavities and the
upper respiratory tract,” according to a question
submitted to the Journal.

“Lymphoid tissue is not found in the sinuses,”
Dr. Glaser said in answer to the inquiry.

Lymphoid tissue, of which adenoids and tonsils
are a part, acts as a filtering station for the watery
fluid of the body called lymph.

X-ray treatment of a regrowth of adenoid tissue
following the removal of the adenoids and tonsils is
an accepted procedure for asthmatic children, he
said. This appears to be helpful in many instances
by eliminating the source of infection which may
trigger asthmatic attacks, he said.

However, such treatment is almost never indicated
in adults because with advancing years such lym-
phoid tissue wastes away. Dr. Glaser pointed out.

An article on x-ray treatment for asthma in a
lay magazine touched off a flurry of inquiries to
A.M.A. headquarters in Chicago.

Test Shows Whether Pain
Is Psychic or Physical

(Continued from Page 61)

The differential diagnosis between physical and
psychogenic pain is often difficult. Dr. Alexander
said, because physicians are frequently faced with
a vexing combination of mental and physical symp-
toms.

Severe physical pain inevitably becomes associ-
ated with emotional suffering, which may evoke
emotional disturbances sufficiently severe to mask
the physical disease and to simulate mental disturb-
ance, he said.

Psychogenic pain, on the other hand, often
causes physical symptoms sufficiently severe to sug-
gest that they are producing the pain, he said.

The psychogalvanic test may prove useful to phy-
sicians who must find the physical illness, of which
pain may be the first sign, before it is too late, or
recognize the psychogenic nature of the pain in
order to be able to rehabilitate the patient, he said.

Dr. Alexander is affiliated with the department of
psychiatry, Tufts University School of Medicine,
and the neurobiologic unit, division of psychiatric
research, Boston State Hospital.

CALIFORNIA MEDICINE

DIRECTORY

HOSPITALS • SANITARIUMS • REST HOMES

luin PineA

NEUROPSYCHIATRIC

HOSPITAL

OPEN, VISITING AND CONSULTING STAFF

BELMONT, CALIFORNIA ESTABLISHED 1925 LYtell 1-8951

In-patient services for acute and chronic
emotional illnesses.

Electric shock Insulin shock

Hydrotherapy Psychotherapy

Occupational therapy

Out-patient services for selective cases

Attending Staff

A. T. VORIS, M.D., Medical Director

DAVID S. WILDER, M.D. • ROBERT E. JAMES, M.D.

ALEXANDER H. MILNE, M.D. • ROBERT L. MEIERS, M.D.

Located 22 miles south of San Fran-
cisco. Accessible to transportation.

ALEXANDER SANITARIUM, Inc. located in the foothills of BELMONT, CALIFORNIA

Address Correspondence: MEDICAL DIRECTOR, Alexander Sanitarium, Inc., Belmont, California • LYtell 3-2143

Occupational facilities consist of special occupational therapy
room, tennis court, billiards, badminton court, table tennis and
completely enclosed, heated, full-size swimming pool.

J. M. CRUIKSHANK, M.D., D.P.H., F.A.C.S., Medical Director

PSYCHIATRISTS: JOHN ALDEN. M.D., Chief of Staff; HEN-
DRIE SARTSHORE, M.D., Asst. Chief of Staff; P. P. POLIAK,
M.D., Asst. Chief of Staff; GEORGE KOLAWSKI, M.D.

A patient accepted for treatment may remain under the
supervision of his own physician if he so desires

COMPTON FOUNDATION
HOSPITAL

FORMERLY COMPTON SANITARIUM

820 West Compton Boulevard
COMPTON, CALIFORNIA
NE 6-1185 NE 1-1148

G. Creswell Burns, M.D.

Medical Director
Helen Rislow Burns, M.D.
Assistant Medical Director

MEMBER OF

American Hospital Association and
National Association of Private Psychiatric Hospitals

High Standards of Psychiatric Treatment
Serving the Los Angeles Area

Fully Approved by Central Inspection Board of APA
Accredited by

Joint Commission on Accreditation of Hospitals

Wbodslde Aws Hospital

Exclusively for the treatment of

ACUTE AND CHRONIC

ALCOHOLISM

MEMBER AMERICAN HOSPITAL ASSOCIATION

1600 Gordon Street • EMerson 8-4134 • Redwood City, California

Advertising

OCTOBER 1962

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Stomach Freezing Successful
In 86 Ulcer Patients

Stomach freezing as a method of treating duo-
denal ulcers has now been used successfully in 86
patients, according to an article in the September 1
Journal of the American Medical Association.

The cases were reported by Drs. Edward T. Peter,
Eugene F. Bernstein, Henry Sosin, Arthur J. Mad-
sen, Arnold I. Walder, and Owen H. Wangensteen,
Minneapolis. Dr. Wangensteen and associates last
May reported the initial trial of the technique in
24 patients.

The technique consists of lowering the tempera-
ture of the stomach to around zero for an hour. A
ballon is inserted into the stomach through which
cold alcohol is circulated to achieve stomach tem-
peratures from four below zero to 10 above zero.

The procedure is “well tolerated” and appears to
depress the secretion of digestive juice, the research-
ers said. The digestive juice containing hydrochloric
acid is believed to be an irritant which, when sup-
pressed, allows the ulcer to heal.

Only time will tell how long the secretion is
suppressed and whether the procedure will have to
be repeated, the authors said.

“Immediate relief of pain has been quite uni-
form,” they reported.

“Healing of duodenal ulcer craters has been ob-
served regularly within two to six weeks.

“The majority of our patients continue asympto-
matic and find it unnecessary to observe dietary
strictures or to take medication.”

The patients ranged from 26 to 82 years, with
the majority in the fourth, fifth, and sixth decades
of life, they said. Most of them had been seriously
considering an operation for relief, they said.

“The simplicity of the method and its effectiveness
in the management of duodenal ulcer suggests it to
be worthy of extended and careful trial,” they said.

In addition to patients with ulcers of the duo-
denum, the first part of the intestine leading from
the stomach, the technique also has been used for a
few patients with problems of the digestive tract
“with improvement,” they said.

So far, they said, they have had limited experience
in treating patients with stomach ulcers with the
freezing technique. However, they said they plan to
explore the possibility of using the method to pre-
vent recurrences of ulcers in the stomach once they
have healed.

The researchers are affiliated with the department
of surgery, University of Minnesota Medical School.

Ascites in Sarcoidosis Due to Peritoneal Involvement:
Report of a Case — Wong, Maylene and S. W. Rosen.
Ann. Intern. Med. — 57:277 (Aug.) 1962.

This report describes a case of ascites due to peritoneal
' sarcoidosis. This is a rare finding in sarcoidosis, and the
clinical and histologic requirements for an acceptable diag-
nosis are emphasized.

CALIFORNIA MEDICINE

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RIKER LABORATORIES, INC., Northridge, California

Exploding Golf Ball
Can Injure Eye

Exploding golf balls have caused a number of eye
injuries, according to Dr. William H. Havener,
Columbus, Ohio.

The explosion is caused by the sudden release of
a liquid rubber compound contained under pressure
in the center of the golf ball.

In a question submitted to the July 14 Journal of
the American Medical Association, a case was de-
scribed in which such an explosion occurred while
a boy was tying to “peel” a golf ball. Particles of
the rubber compound became embedded in his eye.

Dr. Havener said he had seen similar cases. The
injured eye responds to treatment within a week or
so, he said.

Hair Spray Toxicity
Questioned in J.A.M.A.

(Continued from Page 68)

likely, therefore, that pulmonary sarcoidosis will
from time to time appear in women who use hair
cosmetics abundantly since this practice is the cur-
rent, well nigh universal vogue,” he said.

“It would seem that a more specific criterion
should be found by means of which to differentiate
between true thesaurosis and sarcoidosis coinciden-
tal to hair spray exposures.”

The appearance of lung tissue, which forms the
basis for a diagnosis of thesaurosis, is the same

in many cases of sarcoidosis, including men who
have not been exposed to hair sprays, he said.

“In view of the close . . . similarities between
sarcoidosis and certain examples of thesaurosis, the
question is raised whether some cases of alleged
thesaurosis may be instances of pulmonary sarcoi-
dosis coincidental to exposure to cosmetic hair
sprays,” Dr. Schepers said.

Attempts to reproduce thesaurosis in experimental
animals have, thus far, been unsuccessful, he pointed
out.

Dr. Shepers is affiliated with the Haskell Labora-
tory for Toxicology and Industrial Medicine, E. I.
du Pont de Nemours and Company.

Changes in Ego Strength Following Perceptual Depri-
vation— G. D. Cooper, H. B. Adams, and R. C. Gibby.

Arch. Gen. Psychiat. — 7:213 (Sept.) 1962.

This study investigated the hypothesis that positive
changes in ego functioning would occur in psychiatric
patients following a few hours of perceptual deprivation and
social isolation. Cartwright’s modification of Klopfer's Ror-
schach Prognostic Rating Scale was used as a measure of
over-all adequacy of ego functioning. The results supported
the hypothesis. Significant increases were found on the
over-all scale score and on two of the three component
scores. A second finding was that subjects who functioned
least adequately prior to deprivation showed the most im-
provement after exposure to deprivation. The changes ob-
served on the Rorschach measures were consistent with
previously reported postdeprivation changes in overt symp-
tomatology. It was suggested that sensory deprivation tech-
niques might have considerable therapeutic utility with
certain classes of psychiatric patients.

A full complement of
highly trained registered nurses
helps make the patient’s stay
at Camelback Hospital
an infinitely more pleasant one.

A normal ratio of more than
one registered staff nurse
for every two patients
assures maximum attention and
consideration at all times.

Constant care and supervision of patients
is provided around the clock
by the entire hospital staff.

Located in the heart of the beautiful Phoenix citrus area near
picturesque Camelback Mountain, the hospital is dedicated
exclusively to the treatment of psychiatric and psychosomatic
disorders, including alcoholism.

APPROVED BY THE JOINT COMMISSION ON ACCREDITATION

5055 North 34th Street
AMherst 4-4111

OF HOSPITALS; and THE AMERICAN PSYCHIATRIC ASSOCIATION

PHOENIX, ARIZONA

OTTO L. BENDHEIM, M.D., F.A.P.A., Medical Director

CALIFORNIA MEDICINE

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Thiamine Mononitrate

(Vitamin B, ) 2.0 mg

Riboflavin (Vitamin B2) 2.0 mg

Niacinamide (Vitamin B3) 5.0 mg

d-Calcium Pantothenate

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Pyridoxine HC1 (Vitamin B6).. 1.0 mg

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Calcium Lactate 270.0 mg

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Copper (as Sulfate) 0.15 mg

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Potassium (as Chloride) 5.0 mg

Magnesium (as Carbonate) 2.5 mg

COMPLETE LITERATURE AND SAMPLES ON REQUEST.

Mission

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SAN ANTONIO 6, TEXAS

Simple Screening Test Found
For Kidney, Bladder Cancer

A simple test for detecting cancer of the kidneys
and bladder in the “potentially curable stage” before
symptoms become apparent was described in the
September 15 Journal of the American Medical
Association.

Widespread use of the test to screen ostensibly
healthy persons could reduce mortality from such
cancers in much the same way as the Pap smear
test reduced deaths from cervical cancer, according
to the Journal article.

Silent maligant tumors of the kidney and bladder
can be detected by measuring the activity of an
enzyme, lactic dehydrogenase (ldh), through uri-
nalysis, Drs. Warren E. C. Wacker and Lionel E.
Dorfman, Harvard Medical School, Boston, reported.

“It is clear . . . that diagnosis of these cancers
would be made in a significantly earlier stage, with
a consequent reduction in mortality, if the measure-
ment of urinary ldh activities were made a routine
determination on asymptomatic individuals under-
going hospitalization or periodic examination,” they
said.

Successful treatment of malignant disease is influ-
enced more by early diagnosis than by any other
factor, they said. Deaths caused by cancer of the
urinary organs continues at a high level with one-
third to one-half of these patients already incurable
at the time they first seek treatment because of the
late appearance of symptoms, they said.

In a study of 31 patients, ldh activity was ab-
normally high in 18 of 19 patients with cancer of the
kidney or bladder, the only exception being a patient
whose tumor-bearing kidney had been removed, the
researchers reported. Six of the patients with ele-
vated ldh activity were not suspected of harboring a
cancer before they were hospitalized, they said.

Of 12 patients with benign conditions mimicking
malignancies, 5 had elevated LDH activity, they said.
Although the elevated enzyme activity could be ex-
plained in all but one, they said, further study is
necessary to determine if the LDH test can be used to
differentiate between benign and malignant con-
ditions.

The “extreme sensitivity” of the test was demon-
strated by one patient whose LDH activity was only
slightly elevated and who had only a small, low-
grade, malignant tumor of the bladder, the authors
pointed out.

An elevated urinary LDH activity occurs in a
number of serious kidney diseases as well as in
patients with cancer of the kidney and bladder, the
researchers said. However, the differentiation of
these diseases from cancer is easily accomplished,
they said.

Ldh activity in blood and other body fluids has
been used widely in the diagnosis of a large number
(Continued on Page 38)

CALIFORNIA MEDICINE

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Real Doctors Think TV Doctors
Practice Good Medicine

Many physicians think TV’s M.D.’s on such shows
as “Dr. Ben Casey” and “Dr. Kildare” practice good
medicine, according to an article in the October To-
day’s Health magazine, published by the American
Medical Association.

The article, which tells the story of the A.M.A.’s
Physicians Advisory Committee on Radio, Televis-
ion, and Motion Pictures, quotes Dr. Eugene Hoff-
man, Los Angeles, its chairman, as saying:

“Television and motion pictures are practicing
good medicine.

“The dedication to the profession and the sincere
personal interest in the patients exhibited by the
residents and interns on the Casey and Kildare
shows, their financial plight, and their inner work-
ings have given the public an accurate picture of
the long, tough struggle to become a practicing phy-
sician.”

Jim Reed, director of the A.M.A. Communications
Division, voiced much the same view.

“Our mail indicates that the majority of physi-
cians believes that such programs have given the
public an appreciation of the medical profession that
is favorable,” he said.

“The few criticisms we have received from doc-
tors have been based on differences of opinion on
certain techniques or because of dramatic license in
some particular area.”

Typical of comments from practicing M.D.’s was
one received by Dr. Hoffman, which said:

“These medical shows are doing more for our
medical profession than anything that has come
before, and I think that you and your committee
deserve a great deal of credit for keeping the whole
concept authentic and real.”

The American Medical Association advisory com-
mittee was formed six years ago in response to an
appeal by film and TV producers to aid in insuring
medical accuracy on the air and in the movies.
Today the committee functions mainly in Hollywood
and New York with nine members on the West
Coast and three in Manhattan.

More than 3,000 film companies are producing
material for television, the article said, and there are
about 1,000 independent producers and writers. The
committee checks scripts before they are put into
production, it said. Usually, only minor changes
need to be made, although some scripts are rejected
altogether, it said.

Producers and directors make more than 200 calls
a week to the West Coast office, the article pointed
out.

But in spite of the care and watchfulnes of the
committee, Dr. Hoffman said, minor slips are made.

“Fortunately, television’s patients don’t sue for
malpractice, but doctors and nurses who watch the
show don’t hesitate to call our hand,” he said.

The article was written by Larry Wolters.

supervision and companionship

are an integral parr of the therapy program at Camelback Hospital.
Whether patients prefer restful hobbies such as TV viewing,
reading, conversing in the modern, comfortable rooms,
or enjoy more active out-of-doors recreation,
highly-trained, registered nurses are always nearby.

5055 North 34th Street
AMherst 4 4111
PHOENIX. ARIZONA
OTTO L. BENDHEIM. F.A.P.A., Medical Director

CALIFORNIA MEDICINE

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Obesity, Social Class and
Mental Ills Related

Obesity is more prevalent among persons of low
socio-economic circumstances and is associated with
certain mental disturbances, a study of 1,660 New
Yorkers showed recently.

“Obesity is seven times more frequent among
women of the lowest socio-economic level than it is
among those of the highest level; among men the
same relationship exists, although to a much lesser
degree,” Mary E. Moore, Ph.D., and Albert Stunk-
ard, M.D., Philadelphia, and Leo Srole, Ph.D.,
Brooklyn, N.Y., reported in the September 15
Journal of the American Medical Association.

Some 30 per cent of the women in the lowest
socio-economic category were obese and this per-
centage tended to decrease with increasing socio-
economic status until, in the highest socio-economic
status category, only 4 per cent were obese, they said.

Although previous investigations have suggested
a relationship between obesity and social class, they
said, “this is the first controlled study, as far as we
know, that has demonstrated it.”

The study also showed that obesity increased in
prevalence with increasing age and declined among
older age groups, “probably due to the increased
mortality rates among older obese persons.”

This “supports the notion that increase in body
weight with increasing age is a biological character-

istic of man, as of so many mammals,” the re-
searchers said.

Because of the effect of age and socio-economic
conditions, these factors were held constant in an-
alyzing the psychiatric aspect of obesity, they said.
Results of psychiatric tests showed that the obese
persons scored lower on mental health than those of
normal weight. Specifically, the overweight were
more immature, rigid and suspicious to a significant
degree, they said.

“Our results do not indicate whether the mental
health factors are causes of obesity or the results of
being obese in a society that devalues obesity,” they
said.

Documentation of the prevalence of obesity among
low socio-economic groups has “profound implica-
tions,” the three researchers said.

“For it means that whatever its genetic and bio-
chemical determinants, obesity in man is susceptible
to an extraordinary degree of control by social
factors,” they said.

It suggests that a broad-scale assault on the prob-
lem need not await further understanding of the
physiological determinants of obesity. Such an as-
sault might be carried out by a program of education
and social control designed to reproduce certain
critical influences to which society has already ex-
posed its upper-class members.”

Some of the pessimism about the control of
(Continued on Page 48)

for Cerebral Sclerosis • Leg Cramps • Cold Feet * Dizziness

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IMPROVED PERIPHERAL CIRCULATION Symptoms such as cold feet, leg
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The warm, tingling flush which may follow each dose is one of the therapeutic
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Each LIPO-NICIN tablet contains:

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Niacinamide 150 mg. Riboflavin 2 mg.

Ascorbic Acid 100 mg. Pyridoxine HCI 3 mg.

Dosage: 2 tablets daily • Available in Bottles of 100 Tablets

CAUTION: W. B. PARSON, Jr., JAMA, July 30, 1960. Volume 173, No. 13. Demonstrated side reaction
in five of the patients when using substantial dosage of Nicotinic Acid. 3.0 to 7.5 grams daily over a
period of two and one-half years. Suggestion was made that tablets be taken with an anti-acid or with
meals to avoid high acidity in long term therapy. See PDR-page 548.

write for literature and sample:

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CALIFORNIA MEDICINE

REFERENCES

AND REVIEWS

Clinical Appraisal of Cyclophosphamide in Malignant
Neoplasms — H. L. Atkings, H. G. Gregg, and G. A.
Hyman. Cancer, 15:1076 (Sept. -Oct.) 1962.

Cyclophosphamide was administered to 87 patients, almost
all of whom had solid tumors. One-third of the patients
showed some response to the drug, and complications were
few. The drug seemed to be most promising in undifferen-
tiated uterine carcinoma, carcinoma of the ovary, and retic-
ulum cell sarcoma. Leukopenia without thrombocytopenia
appeared regularly. Alopecia occurred in 20 per cent of the

Patients- * * *

I. Analysis of the Immune Agglutination of Red Cells
— H. S. Goodman. Transfusion, 2:327 (Sept. -Oct.) 1962.

The influence of immunologic factors such as antigen and
antibody heterogeneity, number of antigenic sites, and
temperature on agglutination were demonstrated. A quanti-
tative agglutination procedure was used.

* * *

II. Analysis of the Agglutination Reactions Charac-
teristic of the Rh System — H. S. Goodman and L.
Masaitis. Transfusion, 2:332 (Sept. -Oct.) 1962.

The failure of blocking Rh„ antibody to agglutinate Rh
positive cells in saline was found to be due to a disparity
in the binding power of the bivalent sites of the antibody
molecule. Antiglobulin antibodies link two stably attached
antibody molecules. Enzyme treatment of red blood cells
produces agglutination by increasing the binding power of
the Rh„ antigen. The weak agglutination of Rh0 (Du) cells
is due both to a deficiency of the number of antigenic sites
and the weakness of their antibody binding.

Rh„ Variant — Du: I. Its Frequency in a Mixed Popula-
tion; II. Its Detection with Direct Tube Test — P.
Sturgeon. Transfusion, 2:234 (July-Aug.) 1962.

To estimate the frequency of ccDuee in the Los Angeles
blood donor population, a survey based on an initial screen-
ing with Anti-D of 18,365 bloods was made. Approximately
14 per cent (2,635) were D negative; among these, 244 were
either C, D11, and/or E positive. Seven type ccD“ee bloods
were found, five from negroid and two from caucasoid sub-
jects. The respective incidence in the two groups was
found to be 1 in 6,000 and 1 in 500 of the total population
or, in the Rh negative population, 1 in 1,000 and 1 in 25. A
direct tube “stick” test for Du is described. This requires a
high protein reagent and forceful centrifugation.

* * *

Granulomatosis Infantiseptica — P. H. Moore and B. G.
Brogdon. Radiology, 79:415 (Sept.) 1962.

A case of granulomatosis infantiseptica due to Listeria
monocytogenes is recorded to illustrate the major features
of this disease. The radiographic finding of a diffuse miliary
or granular infiltrate superimposed on emphysematous lungs
in a critically ill premature or newborn infant delivered of
a febrile, or recently febrile, mother suggests the diagnosis.
* * *

Results of Treatment in Glomus Jugulare Tumors with
Emphasis on Radiotherapy — J. D. R. Miller. Radiology,
79:430 (Sept.) 1962.

Forty cases of biopsy-proved glomus jugulare tumor (five
cases in a personal series, 35 from the literature) have been
reviewed and divided into two groups on the basis of clinical
features. From the results of treatment it appears that
(Continued on Page 66)

Ideal Fecal yoH
in correction of

CONSTIPATION

encourages laxative Intestinal flora

A stool pH of 6 or 5 usually indicates a
normal lactobacillus flora and a pH of 7
to 9 is abnormal, indicating a deficiency
of lactobacillus - the correlation being
about 94%.'

MALTSUPEX achieves its natural laxative
action by encouraging and maintaining
the growth of low pH lactobacillus flora.
As stool pH approaches 6, patients taking
MALTSUPEX attain a natural laxative ef-
fect. Chronically constipated patients on
a MALTSUPEX regimen were greatly re-
lieved of their constipation and passed
soft, easily evacuated stools, all patients
having a fecal pH between 5 and 6. 2
MALTSUPEX is safe for infants,3 effective
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Dosage, Description and Supply: Adults —
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MALTSUPEX is a nutritive food concen-
trate derived from the natural enzymatic
digestion of barley. It is available as liquid
or quick-dissolving powder in 8 and 16
ounce jars.

References: 1. Raddin, J. B., and Dowell, L. B.:
Amer. J. Gastroent. 37:24-40 (January) 1962. 2.
Calloway, N. O.: Article to be published. 3. Reichert,
J. L.: Pediat. Clin. N. Amer. 2:527-538 (May) 1955.
4. Hootnick, H. L.: J. Amer. Geriat. Soc. 4:1021-
1030 (October) 1956.

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Pillow Feathers Blamed in
Baby's Fungus Disease

Chicken feathers in a 30-year-old pillow were
blamed for causing a fungus disease in a three-
month-old boy.

The case was reported by Hugh E. Evans, M.D.,
and John P. Utz, M.D., Bethesda, Md., and Charlotte
C. Campbell, B.S., Washington, D.C., in the Septem-
ber 15 Journal of the Americal Medical Association.

The disease, histoplasmosis, is caused by the
fungus, histoplasma capsulatum, and is generally
contracted by adults from soil contaminated with
the fungus.

In previously reported cases in infants the source
of the infection was not known, the authors said.

During an extensive search of this patient’s en-
vironment, they said, the fungus was found only
in feathers of the pillow used by the baby, which
had been brought to this country from Hungary 13
years ago.

“At this age he had intimate and prolonged ex-
posure to his pillow, and it is, therefore, reasonable
to assume that this was the mode of infection,” they
said.

Simple Screening Test Found
For Kidney, Bladder Cancer

(Continued from Page 18)

of diseases, including heart attacks, blood clots in
the pulmonary artery, and cancer, they said. How-
ever, data from 200 patients indicate that urinary
LDH activity is not significantly correlated with
blood ldh activity, they said.

The development of a method of measuring uri-
nary LDH activity was made possible by the discovery
of substances that inhibit LDH activity which have
been found in all urinalyses, the researchers said.
Once these inhibitors are removed by a separation
process, they said, determination of LDH is as simple
as that for the enzyme in blood.

The finding of an elevated urinary LDH activity
in patients with cancer of the bladder or kidney
could have been anticipated on the basis of the
disturbed biochemistry of malignant cells, according
to an editorial in the same Journal. Tumor cells
appear to be dependent on a chemical process in
which ldh plays a cardinal role, it said. The meas-
urement of ldh activity in fluids that are in direct
contact with malignant cells has been used previously
as a diagnostic indicator, it said.

To apply this knowledge to urinalysis required
the recognition and elimination of inhibitors of LDH
activity which was possible only through an under-
standing of enzymatic reactions, the editorial said.
Thus the development of this screening is “another
example of the benefits to be derived from advances
in dynamic biochemistry made during the past
several decades,” it said.

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A new drug, mebutamate, has proved useful in
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with severe, progressive or complicated disease who
require a more powerful drug, the authors said.

The drug has a short term of action and must be
taken three or four times a day, they said. It also
causes sedation in some patients, they said.

However, no serious side effects characteristic of
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Mebutamate “would seem a safer, if somewhat less
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used drugs for initial treatment of hypertensives who
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rapidly progressive disease, they said.

The researchers are affiliated with the hyperten-
sive clinic, division of medicine, St. Vincent Charity
Hospital.

Obesity, Social Class and
Mental Ills Related

(Continued from Page 32)

obesity and the preoccupation with individual psy-
chological factors that has stemmed from the study
of upper-class obese persons may not be justified
when considering the numerically far more impor-
tant lower-class groups, they said.

“Perhaps, for example, simple but energetic infor-
mation programs directed to the appropriate groups
could achieve far more than has been thought pos-
sible,” they said.

“Agencies for this purpose are plentiful. Well-
baby clinics and child care centers deal with pre-
cisely the social groups in which the problem is
most pronounced and with just those persons who
determine the family eating patterns. Union, com-
pany, and municipal health programs reach a sig-
nificant part of the men in the crucial social classes.

“A program directed toward these groups could
bring the control of obesity, for the first time, within
the capacity of traditional public health measures.
And the economy of shifting the emphasis from
individual medical to public health measures would
make an informed large-scale attack on the prob-
lem feasible.”

The data which formed the basis for these con-
clusions were collected as part of the Midtown
Manhattan Study, a comprehensive survey of the
prevalence of mental illness, the authors said.
The segment of the population involved in the over-
all study was a group of 110,000 men and women
between the ages of 20 and 59 who occupied a
certain residential area of New York City, they said.

Review of Oral Hypoglycemic Agents — W. S. Metzler,

Canad. Med. Assn. J„ 87:346 (Aug. 18) 1962.

This review embraces early development of oral hypogly-
cemic drugs. Possible errors in administration of too low
initial dosage in the sulfonylureas have been pointed out.
It is indicated that these hypoglycemic agents are estab-
lished now as a form of therapy in a small group of dia-
betics. It is of value to the physician to learn the basic
rules regarding their use.

CALIFORNIA MEDICINE

^ ^MEDICINE

OFFICIAL JOURNAL OF THE CALIFORNIA MEDICAL ASSOCIATION
© 1 962, by The California Medical Association

Volume NOVEMBER 1962 Number 5

The Hazards of Radiation

EDWARD TELLER, P/i.D., Berkeley

Ladies and Gentlemen, it is a very great honor for
me to be with you today and it is a particularly great
honor to be asked to give this lecture in memory
of our good and very great friend, Dr. Ernest 0.
Lawrence. In his life he has done a great many
remarkable things. He was a builder, and the influ-
ence of his work reached from the investigation of
the nucleus to national defense and from there
again, very significantly, to the health of all of us.
When he developed the instrument for accelerating
particles, a development in which he stands above
everybody, he had in mind all along to use the new
nuclear tools for the purposes of medicine. In the
Radiation Laboratory isotopes have been produced
at an early time and there were many years when
the Radiation Laboratory was the source of isotopes
for the whole world. Because of his initiative and
enthusiasm we in this country have a very consider-
able headstart in nuclear medicine.

This is a headstart which we have used well. I
shall mention two very obvious uses. One concerns
our fight against the greatest remaining danger to
human health: cancer. At least in certain stages
some cancer cells are more sensitive to radiation
than the rest of the body. Thus radioisotopes can
be of help in the treatment of cancer. The other point
is even more important. With the help of isotopes

Presented as part of a Symposium on Disaster Medical Care given
at the 91st Annual Session of the California Medical Association, San
Francisco, April 15-18, 1962.

First presented at the First Annual (Pioneers in Nuclear Medicine);
Lecture — at the 7th Annual Meeting, Society of Nuclear Medicine,
Estes Park, Colorado, June 25, I960.

Reprinted, with minor changes by the author, from the Journal of
Nuclear Medicine, 3:1, 1962.

Associate Director of Lawrence Radiation Laboratory, and Profes-
sor-at-Large, University of California, Berkeley 4.

one can follow the particular way in which any
element goes through the complicated maze of bi-
ological activity, and in this way we can have a
detailed and instructive insight into biochemical
processes.

In addition to these great fields that I have men-
tioned, Ernest had a deep interest in one thing. He
saw that the scientific results concerning radiation
have been misunderstood, and he tried to set the
record straight. It is this topic which I want to
discuss with you today.

We have all heard about radiation hazards. We all
know that people are greatly worried about these
hazards. This danger has been exaggerated. There
is a story which many of you may have heard, but I
will repeat it because it illustrates Ernest’s interest
in this particular point.

When the 37-inch cyclotron started to function in
1935 and when neutrons began to come out of this
instrument, one of the very obvious questions was
whether the effects of the neutrons will be similar to
the effects of x-rays, gamma rays, electrons, alpha
particles and other radiation. Because this question
arose, Dr. John Lawrence and Dr. Paul Aebersold
rigged up a little apparatus with a rat inside, which
had to be jammed into a very narrow space in the
cyclotron. The rat confined in this narrow space was
supplied with air which came through a little tube.
The cyclotron was turned on. It ran for two minutes;
Ernest said we better stop, look and see. He stopped
and looked and the poor rat was dead. This caused
an enormous consternation because the rat did not
get a really big dose. It appeared that the neutrons
were much more dangerous than any other radia-

VOL. 97. NO. 5 • NOVEMBER 1962

257

tion. Well, it took a little time to find out the real
story : the tube which supplied the blasts of air to the
rat was closed during the test and the rat suffocated.

This, ladies and gentlemen, was the first of many
alarms about radiation, and like the rest of the
alarms, it had little foundation. Unlike some of the
other alarms, however, it had an advantage. It made
all the people in the Radiation Laboratory very
conscious of the possible danger of radiation, and
partly because of care and I should say partly be-
cause of good luck, there has been a really excellent
record of radiation safety in the Radiation Lab-
oratory.

Starting from these early observations an im-
portant conclusion developed: Nuclear radiation and
radiation damage is a simple thing. The effect of
radiation is to tear molecules apart. There is nothing
particularly specific in this. Some types of radiation
are two or three times more effective than some
other radiation, but by and large any radiation acts
in a similar way as long as it gets into touch with
tissues. The main question is, how much energy is
delivered and to which tissues. Of course, the overall
action may appear quite different. You may have
penetrating radiation which traverses the whole
body, or soft radiation which stops in the skin. There
can be radiation from isotopes which are deposited
in certain organs, and only these organs will be
irradiated. But as long as some tissue is irradiated,
the effect of the radiation is reasonably accurately
estimated, if not really measured, by the amount of
radiation energy delivered to that tissue.

This is in exceedingly sharp contrast with the
effects of chemical agents which have a key and lock
property. A molecule in which you have made a
little substitution can change from a food into a
poison. And to predict, on the basis of chemical
evidence, the biological effects is beyond our present
knowledge and may remain so for some time.
Therefore, to begin with, radiation is a much sim-
pler agent. But I hope that you will not draw the
conclusion from this that therefore its effects upon
us are simple. While radiation is simple, we un-
fortunately are complicated. You do something to
us, and God knows how we are going to react.

The topic which I first want to discuss and which
I want to keep in the forefront for quite some time
is the danger from the worldwide distribution of
radiation — the worldwide fallout from nuclear tests.
And this is the very point that some of us, very much
including Ernest, have discussed frequently and
carefully.

The scare about worldwide fallout is something
about which we must have clear understanding, be-
cause it interacts with very specific medical prob-
lems. As you know, there has been quite a bit of

controversy about nuclear fallout. Some people be-
lieve— maybe some of you believe — that this contro-
versy has been in part caused by the circumstance
that nuclear explosions, nuclear testing and the fall-
out that comes from nuclear testing has been secret
and therefore the general public, even physicians like
you, did not have an opportunity to be fully in-
formed. This statement is only partially right. In
fact, in the main it is just plain wrong. Information
about distribution of nuclear contamination has been
kept secret prior to 1953. In the year immediately
preceding 1955 all of this information was available
to the public. Suspicion did continue that some facts
are held back. This is not true. The record is public
and the record is complete. Then after the record
was complete, radioactivity was dragged into the
political arena in the election of 1956.

Let me try to tell you how some propagandists
who try to scare the people summarize their argu-
ment. Their summary is effective, it is simple, and
it has the appearance of fact. The summary goes like
this. We know that the exceedingly small doses of
radiation which the worldwide distribution of fall-
out will give to the individual has a very small
chance to harm an individual, one chance in 100,000,
or perhaps one chance in a million. But there are
very many people in the world, and if there is one
chance in a million then 3,000 people will be hurt,
and if there is one chance in 100,000, 30,000 people
will be hurt. We should not hurt thousands of
people.

This argument, while it sounds simple and plausi-
ble, is wrong. Fallout has so small an effect that
nobody ever has observed it. And nobody knows
either from direct observation, or from statistics, or
from any valid theory whether the claimed damages
in fact exist or do not exist. I want to talk about
that a lot more, because talking about the effects of
various doses of radiation leads us immediately into
an interesting field of research which should be im-
portant for all of us. The plain fact is that we do not
know what are the effects of small doses of radiation.

At this point the oponents of testing argue: “All
right, we do not know whether this radiation is
dangerous or not. Therefore, wouldn’t you think
that as long as we do not know whether it is danger-
ous or not we should abstain from spreading such
radiation around?” This again sounds like an em-
inently reasonable argument, and I would say
there is a little bit of truth in it, but only a little bit.
There is considerable evidence that the real effects
are very considerably smaller than the effects which
I have mentioned. I believe that exceedingly few
people have been actually harmed by fallout, pos-
sibly the opposite may have been the case. Radiation
might have beneficial effects.

258

CALIFORNIA MEDICINE

Before we continue this argument I want to put
before you some simple facts. Fact Number One I
have already put before you: essentially all radiation
acts in a similar way. How it will act in very small
doses we do not know. But we know that small doses
of neutrons, small doses of x-rays, of gamma rays,
of beta rays, of alpha rays, and of cosmic radiation
will all act very similarly. We know this from phys-
ical evidence; we know it from chemical evidence;
we know it from a concurrence of a great deal of
biological information.

Fact Number Two is this: For more than one hun-
dred million years, ever since fish took the courage
to emerge from the ocean, all of our living ancestors
have been exposed to cosmic rays. And even those
of our ancestors who were sheltered by many feet
of sea water drank radioactive potassium and other
materials; even those were not exempt from radio-
activity. The natural background of radiation to
which we and our ancestors have been exposed is
approximately fifty times as great as the radiation
which we get from all the fallout about which you
have heard so much. In addition, we are exposing
ourselves for good reason to medical x-rays.

Let us consider first only diagnostic x-rays and
not the much discussed therapeutic doses. These
diagnostic x-rays which an average healthy indi-
vidual gets in his life amount to about as much as
the natural background. Therefore, the amount of
radiation that the average individual is getting is
one hundred times as great as the fallout which we
are getting. More than that, natural radiation
changes from place to place a great deal. You are
courageous people for having come up here to Colo-
rado. Do you realize that you are 7,000 feet closer
to the sky, that there is less air between you and
the heavens, and the cosmic radiation, which is much
stronger than fallout, is beating on you with a much
greater intensity than any you could expect from
fallout even where fallout is concentrated. I do not
know how many of you are as foolhardy as I am to
carry a radioactive wrist watch which is hardly visi-
ble to your eyes if you try to look at it at night, but
nevertheless sends a Geiger counter into frantic
activity. The natural background about which we
usually do not hear, about which we usually do not
worry is greater and its changes from one place to
another are greater than anything you can expect
from fallout. This natural background will be differ-
ent if you are higher up. It will be different and
greater if you live in a brick house. It will be differ-
ent if you change your diet. It will be different if
you live in a part of the country where there is a
little bit more thorium or uranium in the ground.
All the prophets of doom are silent about these
dangers which are much greater than the dangers
about which they preach.

Could it conceivably be that, knowingly or not,
these people are worrying about something else than
radiation when they talk about fallout. I understand,
gentlemen, that we here are modest people, interested
in nuclear medicine and not in psychiatry or politics.
Therefore, this last question I will have to leave
unanswered.

I would like to make an appeal to you. A few years
ago there has been introduced a concept which seems
useful — the maximum permissible exposure of a
person. I say that this concept seems useful. I also
say that this concept is most disturbing, misleading,
dangerous, and that you should get rid of it. We do
not know what the effects of small irradiations are.
Therefore we cannot tell what is the maximum per-
missible exposure. And since most of the people who
make such decisions are conservative, they set the
maximum permissible exposure as low as possible
so as to be really safe. Probably ten or one hundred
times the permissible dose will not cause damage
either. Yet, figures are published and then somebody
finds out: “Fve had 20 per cent of the maximum
permissible exposure. I have gone 20 per cent to-
wards some kind of a disaster which I do not under-
stand, but which quite possibly is as bad as getting
cancer.” The alarm that has been spread by this
word, “maximum permissible exposure,” has been
tremendous. And then the experts get frightened and
lower the maximum permissible exposure by a factor
2, and then everybody says: “When will they lower
it again? Perhaps I already have the maximum per-
missible exposure.”

Recently better words have been introduced. In-
stead of “maximum permissible exposure” we should
use the “Radiation Exposure Guide,” a guide which
will be different when you expose the whole popula-
tion, different and higher for professions, different,
still higher in emergency situations where some
chances have to be taken. It is also complicated, and
I would advocate that we don’t talk too much in
public about this guide.

I would advocate that we should talk in public
about one thing only. We should agree on the aver-
age background exposure. Assume the average back-
ground exposure is one-tenth of an “r” per year.
Let us agree on a firm figure and then let us tell
people. The maximum permissible dose is a figment
of man’s imagination. The average background
comes from God, and furthermore since everybody
is exposed to it, is a much more reasonable and
democratic unit. It is also much more reassuring.

The public has been scared into an unreasonable
behavior. Those of you who have the information
must talk not only to their own patients but to the
public and must counteract the unreasonable and
unscientific fear mongers.

VOL. 97. NO. 5 • NOVEMBER 1962

259

I would now like to talk to you about some more
interesting questions concerning fallout. What is
probably the real danger? It has been estimated by
many that due to fallout the lives of some 20,000 or
50,000 people might be shortened. All of this has
been based on a very simple hypothesis. And because
it is simple, therefore it is plausible. And because it
is plausible it is widely used. And because it is
widely used it is widely believed. Yet, the connection
between this hypothesis and truth is exceedingly
tenuous.

The hypothesis is that if one thousand “r” units
do a certain damage or do damage with a certain
probability, then one “r” unit will cause the same
damage with one-thousandth that probability. This
statement is based on the single-hit theory, that is,
the idea that if one molecule is disrupted, the dis-
ruption of this one molecule is irremediable and
will produce an ultimate consequence with a fixed
probability.

Examples of the opposite abound. We know that
something like five hundred “r” units delivered in
one dose will kill half the people if they are healthy,
and more if they are not. Yet, we know that we can
in fractionated amounts deliver one thousand or two
thousand “r” units without any danger of short-
time injury, although some clear-cut danger of long-
range development of some disastrous diseases exists.
Proportionality between the dosage and effect is cer-
tainly not demonstrated. In fact, there is no good
statistical evidence of any damage to the individual,
unless that individual got approximately one hun-
dred “r” units. At the same time, if he gets five
hundred “r” units in one dose, he has a 50 per cent
chance of dying. Therefore the full range in which
proportionality between cause and effect can be ex-
plored is only a range of five-fold change in radia-
tion. In this range the experiments are complicated
and conflicting; some of the evidence clearly con-
tradicts proportionality; other evidence seems to
show proportionality but in an unclear manner. The
evidence is derived from laboratory experiments,
from irradiated populations in Hiroshima and Nag-
asaki, and it comes from therapeutic applications or
radiation. The upshot of these results is that no
clear-cut evidence is obtained for proportionality in
any pathogenic effect.

There have been animal experiments with low-
level irradiation. Even this low-level radiation is one
hundred times as great as the fallout, and there are
essentially no experiments with as low a level as the
fallout. The low-level irradiations have been carried
out by Dr. Lorenz in the National Institute of
Health, Dr. Carlson at Washington State. There are
some indications that when you expose mice and rats
to these low-level radiations, these animals live 10
per cent longer. Many people say the evidence is in-

complete, and I must add on my own — they look
incomplete to me. I don’t know whether the evidence
is conclusive. The simple fact is that when you get
to very low levels of irradiation you do not know
whether the effect is proportional to the first power
of the radiation, whether it is proportional to a
high power of radiation, whether it has a threshold
so that below that threshold there is no damage or
whether below a certain threshold there even are
beneficial effects.

Radioactive waters used to be advertised as bene-
ficial. This claim was unscientific. But the opposite
claim that all radioactivity is harmful is not much
more scientific either. We simply do not know.

I believe that some effects are proportional but
probably only a very few, because most processes in
our bodies are likely to be more complicated and
are not due to one single event. The very idea that
cancer could be caused by one single event flies in
the face of general experience like precancerous
stages, which shows that cancer develops in several
stages rather than being due to one single cause.

Now I would like to mention to you another field
about which we have been fully as much disturbed
- — the genetic effects of radiation. In the genetic
effects the situation is different. Very detailed studies
have shown that irradiation of the spermatozoa of
fruit flies gives rise to mutations strictly proportional
to the dose, and therefore proportionality has been
demonstrated in a wide range between twenty-five
“r” units and four thousand “r” units. I think this is
good, solid, scientific work. But the results are differ-
ent for the spermatogonia and for the Oocytes. If
you have a bare cell nucleus which is stripped down
to the genetic apparatus and contains nothing else,
like the spermatozoa, then indeed the effects are
simply proportional to radiation, and the single-hit
theory seems to be supported. If you deal with sper-
matogonia, the situation is more complicated. Then
you deal with a cell nucleus and a cell body and the
effects of radiation depend on the dose rate. The
effect becomes smaller if instead of a single dose
you fractionate your dose. Repair mechanisms seem
to become possible, and only strong irradiation in
one dose is really damaging. The same seems to hold
for the female cells, for the ovum. In worldwide
fallout the dose rate is small. Spermatogonia and
oozoa may not be damaged at all.

We have heard that fallout produces a terrific
genetic burden. To begin with, radiation from fallout
is only 1 per cent of the radiation which we are
getting anyway. Secondly, I do not think that all
mutations are harmful. All mutations of course are
abnormal because only what is not mutated is what
we call normal; and as every reasonable group of
individuals we believe that we are the peak of cre-
ation. But really to believe this, not emotionally, but

260

CALIFORNIA MEDICINE

intellectually, would seem to deny the simple fact of
evolution. You must allow that something that is
new might be better.

Mutations are increased by fallout, but probably
by less than 1 per cent. Many mutations in us are
probably due to the spermatogonia and oozoa. In
these, fallout probably produces practically no effect.
Furthermore, some very excellent Swedish research
men have pointed out that mutations are caused
because we are foolish enough to wear trousers.
This causes a temperature change in one of our
organs; this will lead to a mutation rate surpassing
the effects of fallout more than hundredfold. The
Swedish geneticists therefore recommended that the
prophets of genetic doom should wear kilts.

There is, ladies and gentlemen, one little point
which I would like to make in all seriousness. There
can be very little doubt that the modern medical art
can keep people alive who otherwise would die.
This increases the number of surviving mutations.
For instance, a person who has diabetes can live
longer and have children. This probably increases
the genetic burden much more than fallout. In a
humanitarian sense it is obviously correct to save
lives. Furthermore, I do not think that this is neces-
sarily a disadvantage from the point of view of the
evolution of the race. Why do we have mutations?
Due to mutations we can adapt ourselves. Can you
think of an age which changes more rapidly than
ours? Can you think of an age where adaptation is
more necessary than it is in ours? By allowing more
mutants to survive we allow more adaptation. Per-
haps those among us who have diabetes and who
can now be kept alive have a linked property of being
temperamentally more suited to live peacefully with
their neighbors. Perhaps they are on the average
more intelligent. Nobody knows. I think that the
expression, “genetic burden,” is ill chosen.

Fallout is not dangerous. But the fallout scare
is. Many people know that a medical x-ray gives you
one hundred times as great a dose as fallout will
give you in your whole life-time. How many people
have been scared away from x-rays? How many
people have gone with their ailments unrecognized
and untreated, only because there has been this need-
less and exaggerated fallout scare? I don’t know.
I don’t know whether anybody has been killed by
fallout, but I am sure that many have been killed
by the fallout scare.

There are many cases in which people were
frightened away from the much more massive thera-
peutical doses. A year ago my sister had trouble
with her thyroid. The tissue had to be removed either
by an operation or by the iodine treatment. You
all know that the operation has some small hazards.
You know also that radioactive iodine treatment is

simple, painless and safe. My mother, who is a
great worrier, almost prevented the iodine treatment,
and it took all my eloquence to put it through. I
wonder how many are the cases in which people
have abstained from needed radiation treatment
because of the fallout scare. There must be many,
many such cases.

It is not unusual that in a serious case of cancer,
a surgeon will undertake an operation, which is dan-
gerous. He will tell the patient that there is a chance
that he will die during or immediately after the op-
eration, and in such a serious operation it is not at
all unusual to accept a hazard, of let us say 20 per
cent. As far as I know, in the case of radiation treat-
ment no hazard is ever accepted. If there is a hazard
of death we abstain from the treatment. I do not see
any logical or sensible reason for this distinction.
Either the procedure of the surgeon is too radical or
else our procedure with radiation is too conserva-
tive. Perhaps our conservatism at present can be
defended on the basis that in many cases we may
not yet know enough. But in principle there must
not be any difference between the two. Radiation
damage is considered today as something unknown,
new, dreadful, something that has to be avoided
under all circumstances. I think this is unrealistic,
and I think that this lack of realism has cost many
people their lives.

This lack of realism can be removed only by very
thorough public education. The problem of explain-
ing radiation hazards is essentially the same whether
you explain the practically nonexistent hazard of
fallout, whether you explain the hardly more exist-
ent hazard of diagnostic x-rays, or whether you are
talking about therapeutic x-rays or irradiations
which are necessarily hazardous. In all three cases
public education is essential, and public education
can be undertaken by no one as effectively as by you.

I know that Ernest Lawrence would not want me
to conclude my talk without emphasizing some posi-
tive aspects of nuclear medicine. We are finding out
more about the effects of radiation. This will result
in more faith in the use of radiation. It will result
and it should result in a wider application of radi-
ation for therapeutic purposes, as a diagnostic tool,
and particularly as a research tool.

There are two great killers left. One, the degenera-
tive circulatory diseases; the other cancer. In both
of these cases the research that is needed in order
to bring help is research which can be done much
better with the help of radioactive isotopes than in
any other way. With the help of radioactive isotopes
you might be able to follow the slow growth, the
slow deposition of unwanted substances on the walls
of an artery or the slow changes in any other organ.
With the help of radioactive isotopes you can find

VOL. 97, NO. 5 • NOVEMBER 1962

261

what chemicals will go to this or that cell, to a
healthy cell or to a cancerous cell. In this way we
might be able to get closer to a meaningful chemo-
therapy of cancer, whether this be chemotherapy
using chemicals that we synthesize or whether it be
chemicals of a more complicated kind, which are
called antigens. It is even possible that the miracle
of the cure of thyroid cancer can be repeated, that
we can incorporate radioactive isotopes into some
molecules which will seek out the cancer cells even
after they have been distributed all over the body,
and in this way get rid of a cancerous condition
in a stage in which no other method is likely to help.

We have so far used in our radioactive research
a relatively small number of radioactive isotopes,
namely, those which live long enough so that they
can be made and then distributed and then used at
leisure. There are many more radioactive isotopes of
a short life. Using these you could open up the
whole periodic system for the purpose of research
and for the purpose of therapeutic irradiation. You
might be able to inject a radioactive isotope in a
very specific location and before the isotope had

much of a chance to migrate away from the location
it would have decayed. Of course, if you want to use
these isotopes you have to have the source of these
isotopes readily available. Fortunately, the sources
of isotopes have become very much cheaper. I hope
that nuclear reactors might appear in all medical
research centers, perhaps in all hospitals. You can
inject the activated substance seconds after it has
left the reactor and in this way you might be able
to use for your research, diagnostic or therapeutic
work isotopes which have as short a lifetime as a
minute or two. We need these isotopes to unravel
biochemistry and to get even closer to this mysteri-
ous complication which we call life.

Ernest had a very unusual ability of taking pleas-
ure in progress, quite independently of whether he
or someone else made that progress. I hope that this
spirit will prevail among us. Only by taking pleasure
in our mutual achievements, only by going ahead
with confidence and courage, will it be possible to
master the enormously complicated field of biochem-
istry, the science of life.

Lawrence Radiation Laboratory, University of California, Berkeley 4.

262

CALIFORNIA MEDICINE

_ . . - — .

Subclinical Hypothyroidism

Recognition and Treatment

PAUL STARR, M.D., Los Angeles

The inadequacy of the basal metabolic rate test for
the diagnosis of hypothyroidism was recognized a
few years ago when it was learned that a patient
with no thyroid hormone in his body whatever could
produce a normal rate of oxygen consumption for
the brief time of the test. This is apparently due
to the extrathyroidal energy mechanisms, such as
the central nervous motor or emotional drive, sys-
temic catacholamine action or steroid metabolism.
Thus, it became clear that hypothyroidism of lesser
degree would usually not be detected if reliance were
placed on the basal metabolic rate.

The determination of the serum protein-bound io-
dine, representing very nearly the amount of cir-
culating thyroid hormone, was demonstrated to be a
much more specific diagnostic measure of hypo-
thyroidism, but an equally important illusion in the
use of this test has become apparent in clinical prac-
tice. For example, a patient may appear to be euthy-
roid, and have such non-specific symptoms that no
clear-cut syndrome of hypothyroidism is present and
yet have a serious degree of thyroxine deficiency as
indicated by the protein-bound iodine (pbi) . Normal
appearing patients may have serum protein-bound
iodine very much below normal. That these patients
do have hypothyroidism is proved by the beneficial
effects of administering thyroid hormone. As the
PBI is raised to normal, physical signs change, previ-
ously unfelt symptoms are demonstrated by their
disappearance, well-being is restored, abnormal
chemical conditions are corrected and vital functions
become healthful, children grow, women ovulate,
pregnancy carries through, hypercholesterolemia is
reduced, anemia is corrected, fatigue alleviated,
fibrositis resolved and mental activity and good
spirits increased. But it must be remembered that
this therapeutic benefit occurs, except for a few
cases described later, only in patients proved to have
hypothyroidism by the demonstration of subnormal
amounts of circulating thyroxine (pbi) and its cor-
rection to a normal level as indicated by the serum

Supported by USPHS Grant A2430 and Baxter Laboratories, Inc.,
Morton Grove, 111. With the assistance of Mrs. Ruth M. Bourke.

Emeritus Professor of Medicine, University of Southern California
School of Medicine, Active Consultant Los Angeles County Hospital,
Los Angeles 33.

Presented before the Section on Internal Medicine at the 9 1st An-
nual Meeting of the California Medical Association, April 13 to 18,
1962.

• Often patients in whom there is little to sug-
gest myxedema or cretinism have subclinical hy-
pothyroidism. Once the condition is suspected,
it can be diagnosed by determination of protein-
bound iodine and, if the PBI is low, by response
to therapy with thyroid hormone.

Patients in the following categories should
have protein-bound iodine determination: Those
having ( 1 ) a history of previous treatment for
hypothyroidism; (2) suboptimal development in
children; (3) ovarian dysfunction, infertility,
habitual abortion or unusual menopausal dis-
orders; (4) symptoms of malaise and debility,
such as undue fatigue, somnolence, mental as-
thenia and anxiety; (5) unexplained anemia;
(6) colloid goiter, adenomatous goiter and can-
cer of the thyroid gland.

If hypothyroidism is diagnosed, administra-
tion of thyroid hormone in increasing amounts,
as determined by serial serum PBI tests, should
be carried out indefinitely. Instruction of the
patient is essential.

protein-bound iodine test. It does not apply to the
many patients who have the same troubles but nor-
mal serum pbi concentrations.

In our clinical experience,5 with the benefit of
convenient and reliable serum protein-bound iodine
determinations,9 patients having such subclinical hy-
pothyroidism are found frequently. The term sub-
clinical hypothyroidism in this connection means
“not appearing to have myxedema.” It would he wise
to screen all patients, with a few exceptions, by
determining the serum protein-bound iodine, just
as we do a routine urine analysis for diabetes or a
blood test for syphilis.6 More extended surveys of
several populations4 have led us to the conclusion
that measurable hypothyroidism is present in the
general population to the extent of 5 per cent. If this
is true, even if over-estimated by half, the practicing
physician should meet this condition frequently.

CLINICAL MATERIAL

The more than 175 cases constituting the clinical
material for this paper were drawn from a small
private practice. The largeness of the number may
be due to the abnormally great index of suspicion
of hypothyroidism in this office. These patients may
be divided into six categories which have been des-
ignated as a result of hindsight — that is, these cases

VOL. 97, NO. 5 • NOVEMBER 1962

263

TABLE 1. — Degrees of Hypothyroidism as Indicated by Protein-
Bound Iodine Content

PBI

( micrograms
per 100 cc. )

Athyreosis or myxedema.

0.0-2.0

Severe hypothyroidism ...

2.0-3.0

Serious hypothyroidism ...

3.0-4.0

Probable hypothyroidism

4.0-5.0

Probable euthyroidism (Male)

4.0-7.0

Probable euthyroidism (Female)

5.0-8.0

TABLE 2. — Distribution of Protein-Bound Iodine Determinations, by

Category,

* in Present Study

PBI 1

( micrograms per IOO

CC. >

Cases

With Less

Cases With

Cases Witli

Than 3.0

3.0 to 4.0

4.0 to 4.5

Category 1 46

Category 11 .... 10

Category 111 .... 2

Category IV .... 5

Category V 2

Totals: Cases 65

19 175

*For description of categories, see text below table.

of subclinical hypothyroidism were discovered be-
cause the following indications led to the perform-
ance of a serum protein-bound iodine determination.
The categories are as follows :

I. Previous surgical or isotope treatment of hy-
perthyroidism (112 cases).

II. Suboptimal development in children (25
cases) .

III. Ovarian dysfunction, infertility, habitual abor-
tion (11 cases) .

IV. Symptoms of malaise and debility, such as
undue nervous and physical fatigue, somnolence,
obesity, hypercholesterolemia, headache and back-
ache (22 cases) .

V. Idiopathic anemia (five cases) .

VI. Colloid or adenomatous goiter and cancer of
the thyroid.

Degree of Hypothyroidism

It is agreed by experienced investigators in this
field that the range of serum PBi values in apparently
normal people is from 4 to 8 meg. per 100 cc. De-
grees of hypothyroidism are indicated in Table 1.

In the present study the distribution of serum PBI
determinations by categories was as shown in
Table 2.

Examples of patients in the categories shown in
Table 2 are presented in the following case reports.

Category I. Hypothyroidism (Neglected) After
Surgical or Isotope Thyroidectomy

Case 1. A woman 31 years of age was first seen
in September, 1953. Fourteen months earlier (July,
1952) she had been given 4 millicuries of radioac-

tive iodine for hyperthyroidism, and, as usual, had
been told to take % grain (15.0 mg.) of dessicated
thyroid twice a day but had been given no explana-
tion of the necessity of determining the quantity of
thyroid hormone needed per diem to render her
euthyroid.

She did not appear myxedematous but was 16
pounds above her previous weight, and had some
premenstrual tension. In eight years of marriage she
had not become pregnant.

On physical examination, there was no exophthal-
mos (bone to cornea measurement, right 15, left 15
millimeters). The pulse rate was 80 and the blood
pressure 115/80 mm. of mercury. The thyroid gland
was not palpable, Chvostek’s sign was not present,
the breasts were normal, lungs clear, abdomen “neg-
ative.” There was no edema or arthritis. Hemoglobin
of the blood was 14 gm. per 100 cc. Leukocytes
numbered 6,900 per cu. mm. The urine was normal.

The indications for a serum pbi determination
were the history of radiation thyroidectomy, infer-
tility and unexplained gain of weight.

The basal metabolism determination, with a good
tracing with even respiration, was — 13 per cent.
The pulse rate was 76.

The serum pbi was 2.0 meg. per 100 cc. and the
serum cholesterol was 317 mg. per 100 cc.

On therapy with sodium levo-thyroxine, now
maintained for eight years, the usual pbi is 7.6 meg.
per 100 cc. A BMR determination was + 15 per
cent with the pulse rate 88.

The patient now has two healthy children. On
last examination (April 1961) she was well and
strong. Body weight was 108 pounds, the pulse rate
80 and blood pressure 110/70 mm. of mercury.

Category II : Suspicion of Suboptimal
Development in Children

Case 2. The patient was a girl, 6% years of age
when first seen in August 1958. When she was 2V2
years old her mother noticed failure of her normal
growth as compared with her two brothers. At that
time, skeletal x-ray examination showed development
equivalent to only nine months. One-half grain (30.0
mg.) of thyroid was prescribed but no attempt was
made to increase the serum PBI to normal. After
three years of this medication the mother was still
dissatisfied with the rate of growth and insisted on
consultation. At this time the pbi was 3.8 meg. per
100 cc. and serum cholesterol 215 mg. per 100 cc.
The bone development was equivalent to that of
three years of age (i.e. 3Vo years delayed). The
height was 40 inches and body weight 45% pounds.
She appeared to be a normal child.

Sodium levo-thyroxine (Synthroid®) 0.1 mg. a
day was prescribed. The PBI in six weeks was 7.9
meg. per 100 cc. A year later, with the patient re-

264

CALIFORNIA MEDICINE

ceiving 0.15 mg. of Synthroid daily, the pbi was 10.1
meg. per 100 cc. The patient had grown 3 % inches
in 10 months, and decided mental and emotional
improvement had occurred.

Nevertheless, a lapse in observation of two and
one-half years then ensued, probably because the
consultant (the author) did not fully educate the
child’s intelligent young mother as to the necessity
for serial observations during the entire period of
growth and maturation.

Now at nine and a half years of age the patient
has grown 4% inches more, to 48% inches. She is
in the third grade at school. On the prescribed dose
of 0.2 mg. sodium levo-thyroxine daily, the serum
pbi is 7.6 meg. per 100 cc., but the bone develop-
ment is still 1% years behind the chronological age
of 9%. It seems probable that although growth and
development have been good from 6% to 9% years
of age, they have not been optimal. The daily dose
has therefore been increased to 0.25 mg. daily,
a 25 per cent increase, and the body and bone meas-
urements will be repeated in six months.

One should anticipate a great increase in optimal
dosage, since the dose requirement of sodium levo-
thyroxine (Synthroid) for young adults is of the
order of 0.5 to 0.8 mg. daily.1

Category III : Ovarian Dysfunction, Infertility,
Habitual Abortion

Case 3. The patient had had panhysterectomy for
menorrhagia and uterine fibroids at age 46. For
two years afterward there was continuous lactation,
associated with nervous anxiety, hot flashes and
somnolence. The appearance of the patient did not
suggest hypothyroidism. Blood cell counts were
within normal range, as were the blood pressure
and the pulse rate. The thyroid gland was not pal-
pable.

The serum pbi was 2.6 meg. per 100 cc. on one
occasion and 2.9 meg. on another in spite of the fact
that she was taking 0.05 mg. daily of ethinyl estra-
diol. Such estrogen therapy has the effect of raising
the TBG* and with it the PBI when additional stores
of thyroxine are available from the normal gland
or from medication. Hence, the degree of endoge-
nous thyroid hormone deficiency in this patient
was severe.

After the patient had been receiving sodium levo-
thyroxine, 0.15 mg. daily for two and a half months,
the serum pbi was 6.8 meg. per 100 cc. and the
serum cholesterol 225 mg. per 100 cc.

Symptomatic recovery was indicated by cessation
of lactation, less fatigue, more endurance, less nerv-
ous anxiety and a general feeling of well being,
expressed by the patient as “feeling better all over.”

•Thyroxine-binding globulin; normal capacity 20 meg. of thy-
roxine per 100 cc. of serum.

Category IV (Women): Symptoms of
Malaise and Debility

Case 4. A 33-year-old mother of three children
8, 6, and 3 years of age went to a physician with
complaint of somnolence and dysphagia. She was
not anemic, had had no history of miscarriages, was
not overweight, in fact, had lost 32 pounds since her
last pregnancy, and had no appearance of myxede-
ma. Nevertheless a serum pbi determination was
done on the order of the physician and the result was
3.9 meg. per 100 cc.

She was given % grain (30.0 mg.) of desiccated
thyroid daily, but a program for attaining optimum
dosage was not laid out. After a year of unadjusted
medication the serum pbi was 2.9 meg. per 100 cc.
Determined twice more within two weeks the results
were 2.4 and 1.7 meg. per 100 cc. Serum cholesterol,
determined at the same times, was 245 and 246 mg.
per 100 cc. The serum thyroxine-binding proteins
were within normal limits, as follows: Tbg 25 per
cent, tba 25.1 per cent, and tbpa 49.3 per cent,
following the reverse flow technique of Tanaka.

I131 uptake was 10 per cent in 24 hours. A scinti-
gram showed uniform distribution of the 250
microcurie dose. Thymol turbidity and cephalin floc-
culation tests were normal.

On sodium levo-thyroxine medication begun in
daily dose of 0.05 mg. daily and gradually increased
to 0.2 mg. daily, the serum pbi in two months rose
to 6.5 meg. per 100 cc. and after four months was
still 6.0 meg.

The patient noted relief of constipation, of right
lumbar muscle pain, of muscular weakness, and of
apprehension in driving her car, and much more
prompt recovery from somnolence. These subjective
observations illustrate the dictum that the patient
often cannot recognize symptomatically that she has
been in an abnormal state of health until after the
abnormality has been corrected.

Category IV (Men): Overweight, Hypertension,
Hypercholesterolemia

The demonstration of subclinical hypothyroidism
in middleaged men is much more dependent on the
physical effects of thyroxine medication than on a
change of symptoms as it is in the women. Further-
more, the occurrence of lower serum PBI in normal
men reduces the chemical borderline. Nevertheless,
the value of the prevention of arteriosclerosis and
atherosclerosis in these subjects, so susceptible to
vascular accidents, indicates a careful therapeutic
trial. The following case is a good example of the
successful use of thyroxine.

Case 5. The patient, first seen in 1949 at 52 years
of age, had recently moved to California from Chi-
cago where he had had frequent nasal sinus infec-

VOL. 97, NO. 5 • NOVEMBER 1962

265

TABLE 3. — Clinical and Laboratory Data, Case 5, Category IV
IMenl: Overweight, Hypertension, Hypercholesterolemia

Dates

9-24-56

11-15-56 tin

ru 7-12-61

Blood pressure

(mm. of mercury)

150/100

146/84

128/80

Weight (pounds)

168

155

160

PBI (meg. per 100 cc.)

3.9

9.0

5.7

Cholesterol

(mg. per 100 cc.)

450

229

233

Thyroid medication

None

Synthroid® 0.3 mg.

Number of determinations

... 13

• • •

tions. He weighed 164 pounds. The blood pressure
was 160/100 mm. of mercury. No distinctly abnor-
mal physical findings were noted. In 1956 the patient
had recently begun to suffer from recurrent obstruc-
tive parotitis (which lasted about four years). The
blood pressure at that time was 160/100 mm. of
mercury. Two years later, when the patient was 58
years of age, serum pbi and cholesterol determina-
tions were done with the results shown in Table 3.

Comment: It seems probable that the administra-
tion of well tolerated doses of sodium levo-thyroxine
to this patient was beneficial. Raising the PBI from
3.9 meg. per 100 cc. to a well sustained value of
about 7.0 meg. has been accompanied by a reduction
of serum cholesterol to about 230 mg. per 100 cc.,
with normal blood pressure, pulse rate (68) and
electrocardiogram. It is important to realize, as this
case indicates, that the correction of subclinical
hypothyroidism results in a reduction of blood pres-
sure as well as a lowering of serum cholesterol.

Category V : Anemia

It is well recognized that anemia is a common
but not universal characteristic of hypothyroidism.
When the hemoglobin is low, and especially if ad-
ministration of iron, folic acid and B12 does not
bring about improvement, consideration should be
given to a pbi test. For example: In one case the
patient had hemoglobin of 11.5 gm. per 100 cc., pbi
of 2.0 meg. per 100 cc. and serum cholesterol of 385
mg. per 100 cc. After six months of treatment with
sodium levo-thyroxine (Synthroid) the hemoglobin
was 13 gm.; a year later it was 14 gm., and it
remained at that level for the ensuing four years.

In another case the hemoglobin seemed to rise as
the pbi rose with faithful adherence to thyroid medi-
cation, and to fall when it was neglected. For
example, with a pbi of 6.1 meg. per 100 cc. the
hemoglobin was 14 gm. per 100 cc. ; and when pbi
was 4.1 meg. the hemoglobin content was 11.2 gm.

Category VI: Goiter and Cancer of the Thyroid

These two conditions may not be characterized
by hypothyroxinemia, but they are examples of a
relative imbalance of the pituitary-thyroid axis, giv-

ing preponderance to thyrotrophic hormone, which
has resulted in thyroid gland disease. This can be
corrected in many instances7 by raising the concen-
tration of thyroxine in the whole body, which causes
the goiter to shrink. Cancer of the thyroid, if of the
hormone-dependent type, is prevented from growing
and spreading1 by continuous high level thyroid
hormone medication.

Case 6. A 54-year-old white man noticed a goiter
for the first time on the morning of the day he
sought medical advice. There had been no acute
pain or sensation of pressure and it must be assumed
that the mass had been present for some time but
had escaped notice. It was on the right side and was
4 cm. in diameter.

The serum pbi was 5.0 meg. per 100 cc. and the
serum cholesterol 269 mg. per 100 cc. The 24-hour
uptake of I131 was 23 per cent and a scintigram
showed diffuse distribution of the isotope. An x-ray
study showed displacement of the trachea to the left.

Administration of sodium levo-thyroxine was be-
gun in June 1961. By January 1962 the thyroid
gland was not palpable on either side. At this time
the patient was taking Synthroid, 0.3 mg. daily, but
the PBI and cholesterol were only slightly changed
from the levels of six months earlier — 6.3 meg. and
246 mg., respectively.

DISCUSSION

Non-myxedematous, subclinical or occult hypo-
thyroidism was stressed by the present author6 in.
1954. It was well dealt with in a brief paper by Lis-
ser3 who said that “the patient may not look myx-
edematous at all, and the dominating or motivating
reason for which relief is sought may lead the con-
sultant astray.” Lisser listed nine categories of
symptoms or disorders that warrant study for pos-
sible hypothyroidism : (1) circulatory; (2) gastroin-
testinal; (3) anemia; (4) arthritis; (5) gynecologic
or urologic; (6) ear, nose and throat; (7) skin;
(8) psychic or central nervous system; and (9)
metabolic phenomena. An excellent and exhaustive
analysis of the problem of the diagnosis of hypo-
thyroidism was given by Wayne10 in the second Lum-
leian Lecture delivered in London, April 1959*
He gave a list of 12 symptoms and nine signs which
may be helpful and said that “when the clinician
fails to recognize an obvious case of hypothyroidism
it is often because the possibility of this condition
has not entered his mind.” How much more must
this be true when the case is not obvious but sub-
clinical or occult. Jefferies, in a recent symposium,2
gave an interesting discussion of patients with “oc-
cult” hypothyroidism and of others having normal
serum pbi with “lowered thyroid reserve.” The pa-
tients designated as having subclinical hypothyroid-

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CALIFORNIA MEDICINE

ism in this report nearly always had subnormal
serum pbi values, except for occasional patients fall-
ing into Category III or Category IV.

Our general conclusion is that there are many
patients, not appearing to be myxedematous, com-
plaining of a wide variety of symptoms or having
systemic or endocrine disorders, who actually have
subclinical hypothyroidism demonstrable by serum
PBI measurements, and that they would be restored
to health by the life-long administration of thyroid
hormone sufficient to maintain normal serum pbi.

1200 North State Street, Los Angeles 33.

REFERENCES

1. Catz, B., Petit, D. W., Schwartz, H., Davis, F., Mc-
Cammon, S., and Starr, P. : Treatment of cancer of the thy-
roid postoperatively with suppressive thyroid medication,
radioactive iodine and thyroid stimulating hormone, Cancer,
12: March-April 1959.

2. Jefferies, W. McK.: Current concepts in hypothyroid-
ism, J. of Chron. Dis., 14:582-585, Nov. 1961.

3. Lisser, H.: The varied symptomatology of hypothyroid-
ism, Trans. Am. Goiter Assn., 457:1955.

4. Lowrey, R., and Starr, P.: Chemical evidence of inci-
dence of hypothyroidism in employed men and women, phy-
sicians, and professional blood donors, J.A.M.A., 171:2045-
2048, December 12, 1959.

5. Starr, P., Petit, D. W., Chaney, A. L., Rollman, H.,
Aiken, J. B., Jamieson, B., and Kling, I.: Clinical experience
with the blood protein bound iodine determination as a
routine procedure, J. Clin. Endoc., 10:1237-1250, October
1950.

6. Starr, P. : Hypothyroidism: An essay on modern med-
icine (Monograph), Amer. Lecture Series, Charles C
Thomas, Publisher, 1954.

7. Starr, P., and Goodwin, W.: Use of tri-iodo-thyronine
for reduction of goiter and detection of thyroid cancer.
Metabolism, 7:287, July 1958.

8. Starr, Paul: Hypothyroidism, Chapter in Current Ther-
apy— 1961 : 343-346. Published by W. B. Saunders Company,
Philadelphia, Pa., and edited by Howard F. Conn, M.D.,
1961.

9. Walter, B. A., Henry, R. J., Ware, A. G., and Starr, P.:
Laboratory and clinical evidence of the reliability of the
alkaline-incinerator method of serum protein bound iodine
measurement, J. Lab. & Clin. Med., 55:643-649, April 1960.

10. Wayne, E. J.: Clinical and metabolic studies in thy-
roid disease, Brit. Med. J., 1:78-90, Jan. 9, 1960.

VOL. 97, NO. 5

NOVEMBER 1962

267

Cerebral Angiography

Its Use in Acute Head Injuries and Undiagnosed Coma

BYRON C. PEVEHOUSE, M.D., and BARTON A. BROWN, M.D., San Francisco

Since the introduction of cerebral angiography
by Egas Moniz in 1927, the recognition and treat-
ment of various intracranial vascular diseases has
attracted great interest. Over the years, the tech-
niques and contrast media used have been improved
to achieve better studies and less risk for the patient.

Today neurosurgeons employ angiography in the
investigation of carotid and vertebral insufficiency,
intracranial masses, spontaneous subarachnoid hem-
orrhage and “cerebrovascular accident” of other
kinds. In some medical centers it is an integral part
of the routine investigation of symptomatology in-
volving the central nervous system. Proper diagnosis
and localization of the lesion has permitted an
aggressive approach in treatment. Endarterectomy
and by-pass procedures on the carotid or vertebral
arteries restore adequate blood supply to the brain.
Patients with subarachnoid hemorrhage may be
salvaged by obliteration of the aneurysm or angioma
and evacuation of the local hematoma. If carotid
ligation is indicated, angiography demonstrates the
individual variations of circulation. Lesions of cere-
bral arteriosclerosis may be recognized and anti-
coagulant therapy begun without delay. In patients
with space-occupying masses, the location, size and
often the exact nature of the lesion may be de-
termined by alterations of vascular pattern. This
important role of cerebral angiography in such con-
ditions, either as an aid in diagnosis or as an
evaluation of treatment, is well recognized.

Beyond this, the purpose of this presentation is
to suggest that cerebral angiography, if performed
in proper facilities and conditions of clinical assess-
ment, can be an essential part of the elucidation of
some acute or “emergency” cases of altered con-
sciousness. Of course, there are many causes of
unconsciousness. At San Francisco General Hospital,
which receives a majority of such problems that
occur within the city limits, the causes in order of
incidence would be ingestion (alcohol and drugs),
head injury, cerebrovascular accident and metabolic
disturbance. However, an alcoholic patient may have
an acute head injury with intracranial bleeding, a

From the Division of Neurological Surgery, University of California
School of Medicine, San Francisco 22.

Presented before the Section on Psychiatry and Neurology at the
91st Annual Session of the California Medical Association, San
Francisco, April 15-18, 1962.

• One of the major factors in treating a patient
with acute alteration of consciousness is to de-
termine if progressive intracranial hemorrhage
is present. Similar problems are encountered in
cases of cerebrovascular disease where increas-
ingly effective medical and surgical methods of
treatment are available. Progressive cerebral
thrombosis can be arrested by anticoagulants,
intracranial hemorrhage can be controlled and
atheromatous occlusion of a major artery can
be corrected. Intracranial mass lesions can be
detected when the history is not available or is
misleading.

Cerebral angiography is a relatively safe diag-
nostic test that is certainly preferable to delayed
or haphazard treatment when an exact diagnosis
is uncertain in an unconscious patient.

diabetic patient may have an inflammatory process
or arterial occlusion in the central nervous system
and the cerebral vascular accident may actually ob-
scure the signs of a brain tumor.

A careful physical and neurologic examination
will often localize the area of dysfunction of the
nervous system, but a detailed history of the pa-
tient’s behavior before loss of consciousness and
the nature of onset is usually necessary to determine
cause. This over-all concept of investigation must
be kept in mind to avoid omissions or premature
conclusions in diagnosis. Unfortunately, the uncon-
scious patient is often brought to an emergency
hospital with absolutely no history available. None-
theless, an accurate diagnosis must be made without
delay, for a number of these patients will die unless
proper treatment is begun quickly.

The cases of simple alcoholism, drug ingestion,
diabetes, hypoglycemic coma, uremia, adrenal col-
lapse, myxedema, electrolyte imbalance and cardio-
vascular failure must be detected. Other patients
will have either acute or subacute alterations of
consciousness due primarily to disorders of the
nervous system. Much can be done to help patients
with these conditions. Simple head injury, menin-
gitis, encephalitis, post-seizure state and most kinds
of cerebrovascular disease do not present a problem
that can be remedied by surgical procedures. How-
ever, conditions such as spontaneous intracranial
hemorrhage due either to rupture of an aneurysm
or angioma, or to primary cerebral hemorrhage with

268

CALIFORNIA MEDICINE

Figure 1. — (Case 1) Parietal occipital glioblastoma multiforme. Left, narrowing of cervical portion of the left
internal carotid artery. Right, staining of parietal tumor shown in venous phase.

intracerebral hematoma, subdural or epidural hema-
toma, partial occlusion of major arteries supplying
the brain, brain tumor or abscess are properly con-
sidered surgical problems and many represent real
neurosurgical emergencies.

In years past, neurosurgical attention to the semi-
comatose or comatose patient with either a severe
head injury or coma of undetermined cause would
consist of multiple exploratory burr holes, and, if
surface hematoma were not observed, needling of
the brain and ventriculography to locate a space-
occupying lesion. Exploratory burr holes involve
multiple skin incisions and permanent skull defects
and as a diagnostic procedure are frequently un-
rewarding. Random brain needling or ventriculog-
raphy may precipitate death in a comatose patient.
On the other hand, angiography may provide a
precise anatomic and etiologic diagnosis and permit
an accurate and definitive surgical operation to
evacuate intracranial mass lesions, to relieve in-
creased intracranial pressure or to alter vascular
occlusion. Recent developments in surgical or enzy-
matic removal of cerebral arterial thrombosis re-
quire angiographic diagnosis and evaluation.

Head injuries will undoubtedy continue to present
a major problem for emergency hospitals. In only
a small portion, perhaps 5 per cent, of all cases of
cerebral trauma is surgical intervention required,
yet there are a large number in which question
arises as to whether or not operation is indicated.
Thus, any study which might more clearly define
the situation and eliminate unnecessary operation
would be welcome.

The patho-physiology of cerebral injury often
hinders proper clinical evaluation of central nervous
system function. The primary need is to determine
whether or not intracranial hemorrhage is occurring
and, if it is, whether bleeding is from severance of
the middle meningeal artery, from laceration of

brain substance or from rupture of cortical veins.
Subpial hemorrhage and devitalized tissues, fre-
quently present in cerebral contusion, produce cere-
bral edema which may simulate a mass lesion.

There are probably many neurosurgeons who,
when considering the possibility of bleeding in a
critical head injury, still obey the dictum, “when in
doubt, put in burr holes.” The number of cases in
which they find no lesions by this means is reported
as evidence of careful attention to patients with
head injuries. Such an approach does not provide
for the abnormally located hematoma over the fron-
tal pole, under the temporal lobe, between the cere-
bral hemispheres, in the posterior fossa or within the
substance of the brain. Nor does it consider the
additional mortality caused from interference with
airway by surgical drapes, vomiting, pharyngeal
secretions, neck flexion and body manipulation in
drilling multiple burr holes under local anesthesia
in a critically injured patient. In the past two years
cerebral angiography has been used on the neuro-
surgical service at San Francisco General Hospital,
and in that time “screening” burr holes rarely have
been needed. Angiography is also used in every case
of head injury in which there is evidence of deteri-
oration or the patient does not improve as rapidly
as could be expected during conservative treatment.

Reports of cases illustrating various uses of angi-
ography follow.

PRESENTATION OF CASES

Case 1. The patient was a 64-year-old white man
admitted with a complaint of four transient episodes
of syncope, each preceded by a feeling of generalized
weakness, vertigo and lightheadedness. He had had
“a heart attack” several years earlier, with a similar
episode of syncope. Upon examination, mild speech
difficulty, right homonymous hemianopsia and in-
coordination of right hand movements were noted.

VOL. 97, NO. 5 • NOVEMBER 1962

269

Figure 2. — (Case 2) Arteriovenous malformation, right
middle cerebral artery.

Figure 3. — (Case 3) Intracerebral hematoma. Arrows
point to slight shift of anterior cerebral artery and de-
pression of left middle cerebral artery.

A diagnosis of basilar insufficiency was made and
anticoagulant therapy recommended. Angiography
revealed a narrowing of the cervical portion of the
left internal carotid artery, and, more important,
the telltale staining of a parietal tumor was seen in
the venous phase (Figure 1). Histologic diagnosis
was glioblastoma multiforme.

Case 2. A 42-year-old white woman was admitted
in emergency with complaint of intermittent severe
headache for 24 hours. She reported tingling of the
left finger tips progressing to numbness of the entire
left side of the body. Upon examination, sensory
disturbance, ataxia, slurred speech and three months
pregnancy were noted. A tentative diagnosis of drug

Figure 4. — (Case 4) Bilateral subdural hematoma. Ar-
rows point to depressed surface of cerebral hemisphere.

ingestion (for attempted abortion) was made. She
had persistent symptoms during a two weeks’ period
of observation. In studies of the spinal fluid, red
cells and xanthochromia were noted. Angiography
revealed an arteriovenous malformation of the right
middle cerebral artery (Figure 2). Surgical excision
of the lesion was followed by compete recovery and
uneventful gestation.

Case 3. A 28-year-old Negro man had sudden
onset of headache while watching television. Right-
sided weakness, aphasia and stupor developed ra-
pidly. Results of examination suggested a left
frontal lobe lesion. Angiography showed a slight
shift of the anterior cerebral artery and depression
of the left middle cerebral artery (Figure 3) . Opera-
tive evacuation of a 40 cc. intracerebral hematoma
deep in the posterior frontal lobe was followed by
satisfactory recovery.

Case 4. A 72-year-old white man, a chronic alco-
holic with a history of repeated head injuries,
seizures and delirium tremens, was admitted to
hospital for the fifteenth time, having been brought
from the city jail in a lethargic state. A diagnosis
of chronic brain syndrome was entertained, but
progressive deterioration of consciousness and the
presence of xanthochromic spinal fluid with in-
creased pressure led to angiography, revealing bi-
lateral subdural hematoma (Figure 4). Evacuation
through burr holes and repeated aspiration of blood
from the subdural space brought about progressive
improvement.

Case 5. A 51-year-old white man was admitted in
semicoma and with continuous generalized seizures.
X-ray films of the skull revealed an old left parietal
craniotomy. Results of examination suggested a
lesion in the right cerebral hemisphere. An angio-

270

CALIFORNIA MEDICINE

Figure 5. — (Case 5) Arrows point to concave outline of
chronic unilateral subdural hematoma.

gram depicted the concave outline of a chronic
subdural hematoma. It was evacuated but the patient
died shortly afterward (Figure 5).

Case 6. The patient was a 31-year-old white man
who had fallen on the street, incurring a scalp
laceration and linear skull fracture. He became
unconscious in a district emergency room and on
admission did not have any lateralizing signs.
Angiography demonstrated horizontal displacement
of vessels by an extradural hematoma, which was
promptly evacuated (Figure 6).

Case 7. A 52-year-old white man was admitted,
semicomatose. There was response to painful stimu-
lation but with the left extremities more active than
the right. X-ray films of the skull showed a fracture
in the right temporo-parietal area. Angiography
revealed a mass in the area of the left temporal lobe
(Figure 7) . A subdural hematoma and small amount
of contused brain were removed from the temporal
fossa. The patient recovered rapidly.

Case 8. A 41-year-old white man had fallen from
bed in an alcoholic stupor, striking his left hip and
the right side of his head. Upon examination, con-
fusion, left hemiplegia and hyperreflexia were noted.
Angiography revealed thrombosis of the right mid-

Figure 6. — (Case 6) Horizontal displacement of vessels
caused by extradural hematoma.

Figure 7. — (Case 7) Left frame shows fracture in right
temporo-parietal area. Right frame shows elevation of
left middle cerebral artery.

die cerebral artery (Figure 8) . Under regular carbon
dioxide inhalations and prolonged physiotherapy,
the patient had partial recovery of function in the
left arm and leg.

DISCUSSION

These cases represent only a few of the studies
that resulted in properly directed surgical measures.
On the other hand, in many diagnostically difficult
cases of head injury and altered consciousness from

VOL. 97, NO. 5 • NOVEMBER 1962

271

Figure 8. — (Case 8) Thrombotic occlusion of right
middle cerebral artery.

other causes, normal angiograms enabled the at-
tending physician to decide against surgical opera-
tion and to initiate such treatment as hypothermia,
cerebral dehydration, correction of fluid and elec-
trolyte disturbance, anticoagulant or anti-convulsant
medication with reasonable certainty that a surgical
intracranial lesion had been excluded.

The acceptable techniques of cerebral angiography
are well known. Emergency measures to establish
an adequate respiratory exchange, to arrest external
hemorrhage, to treat shock and to prevent further
injury should be available at any medical facility,
but the hospital that accepts for definitive treatment
such patients with acute alteration of consciousness
should have angiography available at any time of
day or night. The procedure can be performed
quickly and almost always under local anesthesia,
with premedication if indicated. At San Francisco
General Hospital and University of California Medi-
cal Center, the use of bi-plane radiographic and
rapid changer film units makes it possible to obtain
both antero-posterior and lateral views with injection
of only one 10 cc. injection of contrast media on
each side. Six serial x-ray films, spaced 1.5 seconds
apart, depict the arterial, capillary and venous
phases in each projection. Complications of angi-
ography are usually related to faulty technique of
arterial cannulation or improper injection. The use
of 50 per cent Hypaque® (sodium diatrazoate)
solution in recent years has made a general toxic or
allergic reaction extremely rare. Wende and Schulze1
reported one death and two permanent sequelae
in a series of 2,864 angiograms. They reviewed
37,271 cases reported in the world literature from
1948 to 1959, noting a mortality of 0.16 per cent,
permanent sequelae of 0.1 per cent and transient
sequelae of 1.3 per cent. In the patients herein
described, certainly the possible benefits of angi-
ography far exceeded the risk.

U. C. Medical Center, San Francisco 22 (Pevehouse).

REFERENCE

1. Wende, S., and Schulze, A.: Cerebral angiography and
its complications. A report of 2,864 examinations. Fortschr.
Roentgenstr. 94:494-505. April 1961.

272

CALIFORNIA MEDICINE

Chromosomes of Leukocytes

The Problem of Human Individuality

C. M. POMERAT, Ph.D., Pasadena

The uniqueness of the individual remains one of
the central problems of biology. Extensive current
interest in the almost limitless possibilities for per-
mutations and combinations affecting the configura-
tion of the desoxyribonucleic acid (dna) molecule
provides a solid basis for explaining the concept
that no two organisms, even identical twins, can
be exactly alike. At the practical level, the phe-
nomenon of individuality has been a major preoc-
cupation for anthropologists, psychologists and
students of dermatoglyphics, and inevitably it must
be considered by clinicians in the course of estab-
lishing therapeutic measures and attempting to
assess prognosis. In exploiting chemical studies of
the blood as a means of evaluating metabolic vari-
ables that are a reflection of the state of health of
the individual, we have leaned heavily on the words
of Mephistopheles, in Goethe’s “Faust” — “Blut ist
ein ganz besonderer Saft!” (blood is a very peculiar
fluid). Students of cytology have long sought a
procedure in which a cell sample might readily serve
as the counterpart of the blood specimen in efforts
to quantitate individual differences.

Draper and his associates8,9 made early inroads
in adapting the tissue culture method for this pur-
pose. Unfortunately, the description of morphologic
variations of leukocytes in vitro proved to be ex-
ceedingly difficult to score and the undertaking was
not extended by other investigators. However, two
technical advances that have recently brought a
fresh impetus for the study of human individuality
are proving to be of practical clinical interest
beyond the fundamental knowledge which they can
provide in biology generally. These consist of the
method for the analysis of chromosomes of cells
grown in vitro, and the procedure for short-term
leukocytic cultures in which numerous mitotic fig-
ures can be made available for study.

Many attempts had been made to adapt tissues
from surgical specimens for the evaluation of in-

Dr. Poraerat is Director, Division of Cellular Biology, Pasadena
Foundation for Medical Research, and Clinical Professor of Pathology,
Loma Linda University School of Medicine, Los Angeles 33.

Aided by Grant No. T-249 from the American Cancer Society.

Presented as part of the Basic Science Session at the 91st Annual
Meeting of the California Medical Association, Los Angeles, April
15-18, 1962.

• The technique of chromosome analysis of hu-
man leukocytes after short periods of culture in
vitro gives promise in several areas of basic biol-
ogy and medicine.

Information is being accumulated on the pos-
sibility that stem-line cells in the circulation can
assume hemopoietic function. A large number of
congenital diseases are being described in terms
of chromosomal aberrations. Human blood cells
are found to be useful in the study of radiation,
air pollution and drug injuries. It is possible
that this method may also be helpful in evaluat-
ing various cancer therapeutic measures.

Basic information is needed to assemble tables
of constants regarding variation in the range of
modal chromosome numbers (aneuploidy), as
well as the occurrence of polyploidy and injury
in presumably healthy persons.

dividual differences. With the use of antibiotics to
eliminate the problem of contamination, some hope
was offered in the use of large masses of readily
available tonsillar tissue but this proved to be
complicated by the almost universal presence of
adenoviruses. In contrast to biopsy material which
may not warrant the pain involved, venipuncture to
obtain a 20 ml. sample for chromosome analysis
offers no serious barrier even in the study of
children.

METHODS

On the basis of the classic papers by Hungerford
and co-workers,11 Nowell,17 and Moorhead and co-
workers,15 many modifications have been introduced
with the common goal of providing large numbers
of divisional figures without undue risk of inducing
abnormalities. Since it is well known that there is
a tendency toward hyperploidy in the long-term
growth of adult tissues, culture must be harvested
at the earliest possible suitable moment. Ohnuki
and co-workers18,19 have reported their efforts to
achieve uniformity of results in our laboratory.
Recently, Awa (unpublished) summarized his pro-
cedure as follows:

Heparinized peripheral blood is collected in coni-
cal tubes and immediately after bleeding is allowed
to stand for about 60 minutes at room temperature.

VOL. 97. NO. 5 • NOVEMBER 1962

273

Erythrocytes become agglutinated and settle to the
bottom of the tubes. From the supernatant a number
of leukocytes can be obtained.

An appropriate number of white blood cells, sus-
pended in supernatant, are implanted into T-30
flasks, and 5 ml. of culture fluid (Eagle’s medium
with 10 per cent horse serum) is introduced into
each container. Usually an inoculum with a concen-
tration of approximately 1 x 105 cells per ml. gives
satisfactory results. To this mixture 0.025 to 0.050
ml. of phytohemagglutinin (pha-M, Difco) is
added. The cultures are then incubated at 37° C.
The technique employed in this laboratory for ob-
taining well-spread chromosomes was recently pub-
lished.18

So rapidly have advances taken place in leukocyte
chromosome analysis that workers in this area are
being aided by a novel communications technique:
the distribution of three informal newsletters.13,20,24
The goal of these summaries is to keep investigators
abreast of recent work, much of which is, as yet, not
formally published. These cover normal and abnor-
mal chromosomes, with special reference to congeni-
tal and to malignant diseases, and to radiation
injuries, as well as to new technical advances. Within
the limits of the present paper only the current effort
of our own group will be briefly summarized, with
the hope of illustrating a few directions for future
work which appear to offer promise.

1. Possible recreation of hemopoietic loci

Within a few hours of incubation, well-individu-
alized lymphocytes and monocytes are seen to as-
sume pronounced membrane activity associated with
feeding and locomotion (Figure 1). By the third
day the aggregation of cells around a center made
up of large undifferentiated forms or debris progres-
ses to form colonies which may consist of scores
to several hundred cells (Figure 2). The typical
“hand mirror” forms of lymphocytes, as seen in
phase contrast time-lapse cine recordings, appear
to change polarity and to imbed their caudal gelated
appendages between marginal cells and then con-
tinue to show active undulatory movements of their
anterior membranes. Detailed analysis directed at
identifying cell types and their “ecological” be-
havior, in relation to the possibility that hemopoietic
loci can be reconstituted from adult human pe-
ripheral blood elements, is being conducted by Dr.
Y. Ohnuki. It is notable that Thiery,26 in a study
of plasma cells in the lymph nodes of rats, found
these elements aggregated around large cells de-
scribed as histiomonocytes, which might have a
proliferative or cooperative function as pointed out
by Amano.1

In our preparations mitotic activity appears to be

20 v

rkztX.

<mef:

■ .

, . . * Z , • * • *, t * t Jt

j** * - ; -as '.{£/' v» « -■> ■" o

-tvf % - 1?

/ *T,

Figure 1. — Dark phase contrast microscopy showing an
aggregation of leukocytes, with an extensive undulating
membrane in one of them. The specimen is a one-day
culture. Figure 2. — Bright field microscopy showing colon-
ial organization typical of human leukocytes in vitro,
suggestive of reconstituted “hemopoietic loci.” The speci-
men is a five-day culture.

especially common in the submarginal zone, but
confirmation that lymphocytes can assume active
proliferative capacity awaits further study. Mem-
brane activity at the periphery, as seen in cine
sequences, may function in directing the flow of
nutrients toward the center of the cellular aggre-
gates. In the course of discussions on “blood cell
tissue culture,4 the tenor of opinion was that not
only were stem cells present in peripheral blood,
but that they could be awakened to proliferative
activity under experimental conditions involving a
mucopolysaccharide in phytohemagglutinins acting
either as a mitotic stimulant or in the neutralization
of a plasma factor which normally inhibits mitosis.

An obvious extension of these views leads to the
speculation that peripheral blood, after suitable
cultivation in vitro, might be used to restore hemo-
poiesis to damaged bone marrow. Thus, blood from
a subject having received a sublethal dose of irradi-
ation might be incited to hemopoietic activity in
vitro and within three to six days returned to its
host as an autoplastic graft.

274

CALIFORNIA MEDICINE

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‘ ,gg«««H Ml! V If V If v lyyy

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Figure 3. — Iiliograms of human chromosomes. Normal
male (A) and normal female (C) compared with those
of male and female sibling children having a congenital
syndrome — congenital cataracts, kyphosis, super-extension
of the cervical region and elevated patellae; male (B)
and female ( D ) .

2. Chromosomal aberrations in congenital diseases

The list of clinical entities characterized by vari-
ations in stemline numbers, in “marker” chromo-
somes and other abnormalities is being explored
rapidly in many parts of the world. Dr. Johanna
Blumel, a cytogeneticist attached to the Division of
Orthopedic Surgery at the University of Texas
Medical School in Galveston, was attracted to the
study of a male and female sibling one year apart
in age who were confined in a cerebral palsy home.
They had several common anomalies including
congenital cataracts, kyphosis, super-extension of
the cervical region and elevated patellae. No other
evidence of this syndrome was found in the family.5
Fi gure 3 represents the idiograms of the two affected
children in comparison with those of normal per-
sons. It will be seen that the X chromosome of the
deformed boy (B) and one of the X’s of his sister
(D) were considerably longer than those of corre-
sponding structures in normal males (A) and fe-
males (C). A detailed analysis of these “markers”
is in preparation.

Dobson and Ohnuki' described the chromosomal
abnormalities of a child with a convulsive disorder.
While the modal value in this child was 46, there
were three “marker” chromosomes characterized by
secondary constrictions.

Such studies represent the descriptive phase in
the history of this subject. It is to be hoped that
as we come to know more about DNA synthesis,
about viral disorders which may be associated with
pregnancy and about inborn metabolic errors,
additional light may be cast on the mechanism of
these defects of the mitotic apparatus.

3. Radiobiology and chromosomes

Rapid advances in this area warranted the or-
ganization of a special conference in 1961 under
the sponsorship of the New York Academy of
Sciences.25 In one of the reports, cultures of human
leukocytes treated on the fourth day with 400r from
a cobalt-60 source were found to have chromosomal
injuries in 56.6 per cent of the cells. Polyploidy
increased from 0.1 per cent in the controls to 6.3
per cent in corresponding treated cells.18

Work in progress is designed to compare gamma
with other radiation energies, with the ultimate
goal of using these data as references for the analy-
sis of the effect of exposing human blood cultures
in rockets to radiation as it occurs in outer space.
Unfortunately cultures of blood from the rhesus
monkey for the comparison of radiation injury with
values obtained from human material have not yet
proven satisfactory.19

4. Air pollution and chromosomal injuries

On the basis of experience accumulating in the
evaluation of mitotic injury to various cell species
resulting from tobacco tars,21416 experiments were
conducted in which conjunctival cells (Chang line)
were exposed to automobile engine exhaust gas for
periods ranging from 15 seconds to 24 hours. The
cells showed a decided tendency to chromosomal
clumping (Figure 4) as compared with well-spread
elements in corresponding control cultures (Figure
5). While cytological research generally can be
entrusted only to specialists, the scoring of clumping
can safely be done by competent technicians.22 It
is to be hoped that more end points of this sort
can be found for other experimental studies.

Work in progress is designed to contrast the
action of various noxious gases found in the atmos-
phere, as well as from automobile and industrial
sources, in producing injury to the heteroploid lung
cell line (Nakanishi ) and to one of the diploid
Hayflick and Moorhead cell strains,10 and to human
peripheral blood elements. Such work is also sugges-
tive of opportunities for the evaluation of drug
toxicity, possibly including the potentiality of cer-
tain compounds to induce blood cell abnormality.

5. Evaluation of cancer chemotherapy

In the course of efforts to evaluate the effect of
1-aminocyclopentanecarboxylic acid (NSC-1026) in

VOL. 97. NO. 5 • NOVEMBER 1962

275

TABLE 1. — Peripheral Leukocyte Chromosome Study from Female Patients

Case No.

Sample

Chromosome Number Distribution
46 47 48

Total

Chromosome

Breaks

Per

Cent

Hyperthyroid disease..

\ Before

1/31

3.2

j 3 me. I131 ; 24 hours

5/29

17.2

Carcinoma of thyroid . ..

(Before

4/44

9.1

( 100 me. I131 ; 24 hours.

1/20

5.0

Hyperthyroid disease..

f Before

1/50

2.0

(8 me. I131; 24 hours

. 40

5/421

11.9

Hyperthyroid disease..

j Before..

0/22

( 5 me. I131 ; 24 hours

1/37

2.9

(Before

3/31

9.7

Hodgkins disease

- ilOOOr Co00; 1 week

3/41

7.3

( 2750r CoG0 ; 31 days

2/41

4.9

-This patient had been treated with 100 me. I131 three months previously and had had thyroidectomy;
some study.

fTwo secondary constrictions were included.

10 me. of I131 at time of chromo-

Figures 4 and 5. — Human leukocytes treated with the
chromosome-spreading technique after six days in vitro
and stained with orcein, illustrating clumping (Figure 4)
in comparison with a spread pattern (Figure 5).

the management of multiple myeloma,21 the karyo-
types of cells from the huffy coat were studied
before and after therapy. While the data were
limited in extent, they suggest an important chal-
lenge for cancer chemotherapy.

Chromosomal aberration after diagnostic x-irra-
diation has been reported by Stewart and Sander-
son23 and by Tough and co-workers.27 Baikie and
his associates3 observed that three patients with

TABLE

2.-

-Distribution of Chromosomes in Cells of Healthy,
Persons

Number of Chromosome per Cell

.*■ 33. ..45 46 47 48 49 SO... 92+1

c 4

444444 4

« Number of Cells Containing That Number

-< 4

444444 4

Cells

li .

.. 151

151

26 3 1

27 ..

. 119

120

27 ..

1 59 ..

34 ..

.. 147 11

150

34 ..

.. 30

39 ..

55 ..

.. 205 1 .. .. 1 1

210

11 ..

.. 72

23 1

168 1

170

25 ..

56 3

33 ..

1 1113 6 2 0 1 4

1133

98.23 %

*E: Endoreduplication.

ankylosing

spondylitis showed abnormal

chromo-

some

pattern in

leukocytes which were

cultured

following

x-ray therapy to the spine. A preliminary

communication on the damaging effect of

radio-

iodine

doses of 6 to 150 millicuries in

six men

and two women

has been presented by Boyd and

co-workers.6

While it would appear that documentation of
chomosomal injury was primarily useful in the study
of radiation health hazards, quite a different use
may be made of such findings. We are at present
engaged in attempting to determine whether corre-
lations can be found between tumor regression and
chemotherapy, radiotherapy and immunotherapy as
reflected by changes in the chromosomal pattern of
the patient’s leukocytes. Desiderata in setting up
this program include (1) the study of persons with
malignant disease diagnosed by histopathological
criteria and no previous therapy, (2) at least two
examinations of the blood before therapy is insti-
tuted, and (3) follow-up for a suitable period during
the course of therapy, together with regular precise

276

CALIFORNIA MEDICINE

clinical appraisals. Table 1 shows preliminary ob-
servations by H. Oishi. Obviously, since the sample
size, type and dosage of the therapeutic agent as
well as the time interval following treatment must he
documented for a variety of pathological entities as
well as for subjects treated for non-malignant proc-
esses, gathering the large body of data needed will
require a great amount of exacting work. While the
data presented are statistically inadequate and there-
fore do not deserve extensive discussion, they indi-
cate the type of information which may ultimately
prove useful.

6. Constants for human chromosomal variation

In the course of radiobiological and other in-
vestigations, collected data on control material are
being added to growing knowledge accumulated in
other laboratories for describing the range of vari-
ation in aneuploidy, polyploidy and the occurrence
of abnormal chromosomes in presumably healthy
persons in relation to sex and age. Table 2
presents recent data by Y. Ohnuki and A. Awa. A
large body of data has been contributed to this
literature by Jacobs and co-workers.12 Two difficul-
ties are inherently present in the documentation of
chromosome constants: (a) uniformity of technical
procedures, and (b) the enormous labor of pre-
paring the reliable idiograms needed for accurate
results. Nonetheless, such information is urgently
needed.

Pasadena Foundation for Medical Research, 99 North El Molino,
Pasadena.

REFERENCES

1. Amano, S.: The cytological basis for allergy and im-
munity (translated), Trans. Soc. Path. Jap., 35:43-45, 1946.

2. Awa, A., Ohnuki, Y., and Pomerat, C. M.: Some com-
parative effects of smoked paper, tobacco and cigarettes on
chromosomes in vitro, Texas Rep. Biol, and Med., 19:518-
528, 1961.

3. Baikie, A. G., Jacobs, P. A., McBride, J. A., and
Tough, I. M.: Cytogenetic studies in acute leukemia, Brit. J.
Med., 1:1564-1571, 1961.

4. Blood-Bone Marrow Tissue Culture and Cell Separa-
tion Conference, sponsored by the Oak Ridge National Lab-
oratory and the NIH, 20-21 October 1961, Fundamentals
and Clinical Aspects of Radiation Protection and Recovery,
Booklet No. 4, 1961, Blood (in press).

5. Blumel, J., Ohnuki, Y., and Awa, A.: Chromosome
anomaly in two cases of cerebral palsy, a brother and a sis-
ter, Nature, 189:154-155, Jan. 14, 1961.

6. Boyd E., Buchanan, W. W., and Lennox, B.: Damage
to chromosomes by therapeutic doses of radioiodine, Lancet,
i:977-978, 1961.

7. Dobson, Rosemary, and Ohnuki, Y.: Chromosomal ab-
normalities in a child with a convulsive disorder, Lancet,
ii :627-630, Sept. 16, 1961.

8. Draper, G., Pierce C., and Dupertuis, C. W.: The re-
lationship between cells and plasma in cultures of buffy
coat from human blood, Am. J. Med. Sci., n.s. 210:738-745,
1945.

9. Draper, G., Ramsey, H. J., and Dupertuis, C. W.: Vari-
ation in behavior of buffy coat cultures among individuals
of different constitution types, J. Clin. Invest., 23:864-874,
1944.

10. Hayflick, L., and Moorhead, P. S.: The serial cultiva-
tion of human diploid cell strains, J. Exp. Cell Res., 25:585-
621, 1961.

11. Hungerford, D. A., Donnelly, A. J., Nowell, P. C.,
and Beck, S. : The chromosome constitution of a human
phenotypic intersex, Am. J. Human Genet., 11:215-236,
1959.

12. Jacobs, Patricia A., Court-Brown, W. M., and Doll,
R.: Distribution of human chromosome counts in relation to
age, Nature, 191:1179, Sept. 6, 1961.

13. Mammalian Chromosomes — Newsletter. Section of
Cytology (Dr. T. C. Hsu, ed.), M. D. Anderson Hospital
and Tumor Institute, Houston, Texas.

14. Mizutani, M., Ohnuki, Y., Nakanishi, Y. H., and
Pomerat, C. M.: The development of a near-diploid in
vitro strain from a smoke-condensate induced mouse tumor,
Texas Rep. Biol, and Med., 18:455-469, 1960.

15. Moorhead, P. S., Nowell, P. C., Mellman, W. J.,
Batipps, D. M., and Hungerford, D. A.: Chromosome prepa-
rations of leukocytes cultured from human peripheral blood,
Exp. Cell Res., 20:613-616, 1960.

16. Nakanishi, Y. H., Mizutani, M., and Pomerat, C. M.:
Smoke condensates on lung cells in tissue culture with spe-
cial reference to chromosomal changes, Texas Rep. Biol,
and Med., 17:542-590, 1959.

17. Nowell, P. C.: Phytohemagglutinin: An initiator of
mitosis in cultures of normal human leukocytes, Cancer
Res., 20:462-466, 1960.

18. Ohnuki, Y., Awa, A., and Pomerat, C. M.: Chromoso-
mal studies on irradiated leukocytes in vitro, Ann. N. Y.
Acad. Sci., 95:882-900, Nov. 13, 1961.

19. Ohnuki, Y., Awa, A., and Pomerat, C. M. : A com-
parative study of human and monkey leukocytes in culture,
Report to School of Aerospace Medicine, USAF (in press).

20. Puck, T. T.: Animal Cell Information Service, Edi-
torial Committee: Department of Biophysics, University of
Colorado Medical Center, Denver 20, Colorado.

21. Richmond, H. G., Ohnuki, Y., Awa, A., and Pomerat,
C. M.: Multiple myeloma — an in vitro study, Brit. J. Can-
cer, 15:692-700, 1961.

22. Rounds, D. E., Awa, A., and Pomerat, C. M.: The
effect of auto exhaust on cell growth in vitro, A.M.A. Arch.
Environ. Health (in press).

23. Stewart, J. S. S., and Sanderson, A. R.: Chromosomal
aberration after diagnostic X-irradiation (Preliminary Com-
munication), Lancet, i:978-979, 1961.

24. The Human Chromosome Newsletter. Edited by David
G. Harnden and Patricia A. Jacobs. Medical Research Coun-
cil, Clinical Effects of Radiation Research Unit, Western
General Hospital, Edinburgh 4, Scotland.

25. The Use of Animal Cell, Tissue, and Organ Cultures
in Radiobiology (C. M. Pomerat, Conference Editor), Ann.
N. Y. Acad. Sci., 95:741-1020, Nov. 13, 1961.

26. Thiery, J. P.: Microcinematographic contributions to
the study of plasma cells, Ciba Foundation Symposium,
Cellular Aspects of Immunity, pp. 59-91, 1959, Little, Brown
& Co., Boston.

27. Tough, I. M., Buckton, K. B., Baikie, A. G., and
Court-Brown, W. M.: X-ray-induced chromosome damage in
man. Lancet, ii:849-851, 1960.

VOL. 97, NO. 5 • NOVEMBER 1962

277

Decrease in Serum Cholesterol with Surgical Stress

JOSEPH R. GOODMAN, Pfi.D., San Francisco; FREDERICK KELLOGG, M.D.,
ROBERT W. PORTER, M.D., and ROBERT LIECHTI, M.D., Long Beach

Several reports have appeared correlating stress
with increases in serum cholesterol levels in man*
In them the investigators speculated on the relation-
ship of stress and cholesterol increases to the etiol-
ogy of atherosclerosis. The stress studied was mental
tension in students during examinations or in men
during periods of increased occupational activity
typical of some seasonal businesses. In contrast,
decreases in serum cholesterol have been correlated
to the stress of surgical operation7,8 and myocardial
infarcts.1,0 In these studies adequate control levels
before the stress were lacking, for it was not feasible
to obtain pre-infarct values and the surgical study
used reference values from specimens taken just
hours before operation.

The present study was undertaken to evaluate
cholesterol changes with surgical operations under
more adequate control conditions.

METHODS

Previous data noted in a report on myocardial
infarcts by Kellogg6 suggested a further inquiry
into serum cholesterol changes in selected stress
situations. Two series of male patients were studied.
One was made up of 28 patients who were admitted
to hospital for elective surgical operation several
days before the day set for the procedure. Two or
more specimens of serum were obtained before
operation and one specimen on the morning of
operation. Cholesterol determinations then were
done on two or more specimens up to eight days
after operation.

The other group was composed of 21 patients
admitted with a diagnosis of ruptured intervertebral
disc. This group was of particular interest, for the
patients were put in hospital for bed rest, observa-
tion and possible surgical operation, thus providing
for control levels over a period of two to three
weeks. These patients also presented the opportunity
to examine the effect of mental stress before opera-
tion, since the decision regarding surgical interven-
tion was not made until the results of conservative
treatment were evaluated.

The second group naturally divided into those
who did not have operation (12 patients) and those

Submitted March 21, 1962.

‘References 2, 3, 4, 10, 11.

• Serum cholesterol levels decreased with the
stress of operation, before the procedure or after
it, or before and after. This decrease was 17.6 per
cent in a group of 28 elective surgery patients
and 20.4 per cent in nine ruptured intervertebral
disc patients who had an operation. A presurgical
drop was noted and considered to be related to
psychological stress.

who did (nine patients). The total period of ob-
servation averaged about 20 days for those who
were not operated upon and about 30 days for
those who were. Six to 17 specimens of blood taken
before breakfast were collected from each patient.
Cholesterol analysis was done by the method of
Kanter and co-workers.5

RESULTS

Twenty-seven of the 28 patients with elective
operations showed a decrease in serum cholesterol
levels — all but one having some decrease before and
all but six some further decrease after operation.
Twenty-three of them had maximum decrease of
more than 10 per cent of initial levels. The average
decrease was 17.6 per cent with a range of 5 to 40
per cent. Changes from initial levels to the morning
of operation, as well as changes from the immediate
preoperative levels to the postoperative minimum,
were also analyzed. During the preoperative period
the serum cholesterol level of 26 patients decreased
an average of 12.4 per cent. Sixteen of these had a
decrease of over 10 per cent from control levels.
Twenty-one patients had additional decreases after
operation, the average decrease being 9.2 per cent.

Chart 1, line A, shows the curve of average values
with the day of operation as zero time. Since all
samples were not taken on the exact day in reference
to the day of operation, some grouping or rounding
of the time scale was employed. That is, data from
samples collected on the sixth, seventh or eighth
day were grouped for average calculations and
graphed as the seventh day point. The — 1, 0 and
+ 1 day values were taken on the day before opera-
tion, on morning of operation and the morning
following operation. This group of 27 patients con-
sisted of five having hemorrhoidectomy, 14 having
herniorrhaphy, two removal of varicose veins, two
abdominal perineal resections, one removal of thy-

278

CALIFORNIA MEDICINE

Chart 1. — Serum cholesterol changes with surgical
stress. Line A, average total cholesterol values of 28
patients admitted for elective operation. Line B, average
values of 12 patients with intervertebral disc disease who
did not have operation. Line C, average serum cholesterol
on nine patients with disc disease who were operated
upon. Surgical operation (S) was performed at day 0.

roicl nodule, one removal of pilonidal cyst, one
pyloroplasty and one thyroidectomy. Careful exam-
ination of the cholesterol changes showed no corre-
lation with the type of anesthesia or operation.

The 12 patients admitted for observation of
possible ruptured intervertebral disc who did not
have operation showed some variation in average
cholesterol levels (Chart 1, line B). The maximum
change in these averages was 5 per cent, although
individual variation was greater than this. There
was no evidence of any change in these averages
that could be related to hospital diet, major periods
of bed rest or the stress of indecision about surgical
intervention.

The nine patients who did have operation (Chart
1, line C) had an average presurgical decrease of
9 per cent in serum cholesterol levels. There was an
additional decrease of 12.8 per cent immediately
after operation, which was followed by a gradual
increase to a level that was still below initial levels
at 11 days after operation. In some patients the
initial decreases were as early as four days before
operation, at the time they were told of the forth-
coming procedure. The data in Chart 2, line A,
concern a patient with a very stable cholesterol level
during the control period and a clear decrease at
the time he was told an operation was to be per-
formed. Lines B and C of the chart show the choles-
terol changes in two other patients with decreases
before operation, then a further decrease after
operation.

DISCUSSION

Serum cholesterol levels decreased with the stress
of surgical operation, either before or after opera-
tion or before and after. The two groups of patients

Days

Chart 2. — Changes in serum cholesterol in three persons
who had intervertebral disc operations. Day 0 is the day
of surgical operation (S). The time (T) that patients
were told of the decision to operate was four days before
the day of operation.

who had operations showed average total decreases
in cholesterol of 17.6 per cent and 20.4 per cent.
The initial group of patients was observed for
periods up to one week before operation. This short
control period might not reveal the effect of such
factors as bed rest and hospital diet. The second
group of patients was observed for two to three
weeks before they were operated upon. This period
of time provided for better control levels. However,
the longer observation time did not reveal signif-
icant changes in cholesterol levels with hospitaliza-
tion and its attendant changes in the patients’
routine.

The stress of operation was both psychological
and physiological. The psychological stress of anxi-
ety in anticipation of operation was accompanied
by an initial decrease in cholesterol. This varied
with the individual, some responding with a decrease
immediately upon being told of the decision to
operate; in others this change occurred 24 hours
before operation. No change in diet or preoperative
medication had been initiated up to this time. The
physiological stress of the operation was followed
by an additional cholesterol decrease — a decrease
that occurred under stress conditions relating to the
integrity or survival of the body. In contrast the
increases in cholesterol previously reported occurred
with stresses more related to social status and recog-
nition of success in society.

Peterson and co-workers9 presented cholesterol
changes in response to stress, wherein the students
observed were grouped according to the stability
of their serum cholesterol levels. This study included
five “labile” students who showed changes related
to mental stress. A consistent serum cholesterol
decrease was correlated with a previous period of
apprehension. An increase in cholesterol occurred
before an anticipated exposure to cold. It is not

VOL. 97, NO. 5 • NOVEMBER 1962

279

clear how these observations may relate to the
decreases in cholesterol that occur before surgical
operation. The changes in this group of students
were transitory (hourly variations), while the data
in the present study in surgical situations were on
a daily basis.

Veterans Administration Hospital, 42nd Avenue and Clement
Street, San Francisco 21 (Goodman).

REFERENCES

1. Biorck, G., Blomquist, G., and Sievers, J.: Cholesterol
values in patients with myocardial infarction and in a nor-
mal control group, Acta. Med. Scand., 156:493-497, June
1957.

2. Dreyfuss, F., and Czaczkes, J. W. : Blood cholesterol
and uric acid of healthy medical students under stress of
examination, A.M.A. Arch. Int. Med., 103:708-711, May
1959.

3. Friedman, M., Rosenman, R. H., and Carroll, V.:
Changes in serum cholesterol and blood clotling time in
men subject to cyclic variation of occupational stress, Cir-
culation, 17 :852-861, May 1958.

4. Goudy, S. M., and Griffin, A. C. : Effects of periodic
mental stress to serum cholesterol levels, Circulation, 19:
496-498, April 1959.

5. Kanter, S., Goodman, J. R., and Yarbough, J.: Deter-
mination of free, ester and total cholesterol without saponi-
fication, J. Lab. Clin. Med., 40:303-312, Aug. 1952.

6. Kellogg, F., and Goodman, J. R.: Viscosity of blood in
myocardial infarction, Circul. Research, 8:972-979, Sept.
1960.

7. Kyle, L. H., Hess, W. C„ and Welsh, W. P.: Effects of
ACTH, cortisone and operative stress upon blood cholesterol
levels, J. Lab. and Clin. Med., 39:605-617, April 1952.

8. Man, E. B., Bettcher, P. G., Cameron, C. M., and
Peters, J. P. : Plasma a-amino acid nitrogen and serum lipids
of surgical patients, J. Clin. Invest., 25:701-708, Sept. 1946.

9. Peterson, J. E., Wilcox, A. A., Haley, M. I., and Keith,
R. A.: Hourly variation in total serum cholesterol, Circula-
tion, 22:247-253, Aug. 1960.

10. Thomas, C. B., and Murphy, J.: Further studies on
cholesterol levels in Johns Hopkins medical students: The
effects of stress at examination, J. Chron. Dis., 8:661-668,
Dec. 1958.

11. Wertlake, P. T., Wilcox, A. A., Haley, M. I., and
Peterson, J. E.: Relationship of mental and emotional stress
to serum cholesterol levels, Proc. Soc. Exp. Biol. Med., 97 :
163-165, Jan. 1958.

280

CALIFORNIA MEDICINE

Prenatal Care

A Group Psychotherapeutic Approach

RONALD JOSEPH PION, M.D., JOSHUA S. GOLDEN, M.D., and
ALEXANDER B. CALDWELL, JR., Ph.D., Los Angeles

In the field of obstetrics, much has been written
regarding the emotional requirements of the prenatal
patient.1'2,1218'22 and varying attempts at teaching
psychiatric skills to the resident are being made.10
Ideal prenatal care should have as its goals not only
the continuing reduction of morbidity and mortality,
but the emotoional well-being of the patient and her
family as well. Programs have variably stressed
education, relaxation and exercise,8'24 and have util-
ized physical therapists and lay educators in order
to free the obstetrician-nurse team to deal more
effectively with the reduction of morbidity. It is
difficult to criticize the value and merits of the indi-
vidual programs. Certainly all are good in the sense
that they attempt to answer a need. Whether the
relegation of authority away from the physician is
a good thing has been questioned.13’17

Although the present-day medical curriculum em-
phasizes the need for recognition and treatment of
psychosomatic aspects of disease, too often in pur-
suit of specialty training programs, the resident
physician finds little time available to deal effectively
with even the most superficial anxieties that trouble
his patients. Usually these anxieties are countered by
authoritative reassurances and generally harmless
drugs, which fortunately in the majority of instances
offer sufficient temporary relief. This way of dealing
with such problems may stem from a tacit “under-
standing” between physician and patient. The pa-
tient disguises emotional problems in a garb of
physical complaints, and the resident physician,
Seven though aware of the emotional origin of the
problems, willingly treats them as physical. If the
“palliative tablet” does not help or the emotional
problems are more severe, psychiatric referral is
always at hand. This practice avoids the strain of
closer personal involvement with patients and helps
perpetuate the dichotomy already existing between
the treatment of physical and emotional disease.

From the Department of Obstetrics and Gynecology, and the
Department of Psychiatry, University of California School of Medi-
cine, Los Angeles 24.

Presented before the Section on Obstetrics and Gynecology at the
91st Annual Session of the California Medical Association, San
Francisco, April 15-18, 1962.

• It has been well established that “normal”
pregnancy gives rise to much anxiety whose
source is variable. When not adequately dealt
with, the anxiety may masquerade in the guise of
physical symptoms such as fatigue, dizziness,
nausea and vomiting, or, more often, as disquiet-
ing emotional counterparts, like irritability and
depression.

A study was undertaken in the outpatient
obstetrical department at U.C.L.A. utilizing a
group psychotherapeutic approach. The results
helped the patients and offered training to staff
in dealing with emotional problems of preg-
nancy. Patients were seen in groups of seven,
twice a month for one-hour sessions. Participating
in each group were an obstetrical resident, a
psychiatric resident and a nurse. The subject
material was not selected beforehand. Groups
were similar in that the expected time of delivery
of the patients was approximately the same. Re-
sults of the study suggested that the much
needed emotional support may be supplied in
this way with little to no additional time ex-
penditure on the part of the physician or nurse.

The authors pondered whether many of the pro-
jgrams might not be allaying anxiety indirectly
rather than getting down to the primary sources,
and, further, whether the obstetrician could not deal
with these more directly and thus more effectively.
Could it be done without further encroaching upon
the time of the busy resident who was desirous of
offering his patient more than routine care?

For answers, using group psychotherapeutic tech-
niques, we attempted to utilize the well established
principles of prenatal care and at the same time
more directly meet the emotional needs of the
patient. Group therapy has been shown to be an
effective method of treating anxiety associated with
a variety of illnesses, both psychic and soma-
tic.G’9,23’30 Its use in obstetrics, in a formal sense,
is rare, and its use with a psychiatrically “normal”
pregnant population has been reported only twice to
our knowledge.7,16 Although group processes are
an integral part of many prenatal programs, they
generally are used in an indirect fashion. It is quite
common, however, to find groups of women sharing
their experiences about pregnancy.12,18

VOL. 97, NO. 5 • NOVEMBER 1962

281

Our study was based on the following considera-
tions: (1) All “normal” pregnant women have
substantial amounts of anxiety which ultimately
affect the course of the antenatal period both phys-
ically and emotionally, their labor and delivery and
their subsequent relationship to the newborn and
to their family. (2) Many sources of the anxiety can
he readily discovered and understood, and the
anxiety diminished by utilizing group therapeutic
techniques. (3) Such a program is practical for
teaching residents, students and nurses how to deal
with the emotional problems of pregnant women.
(4) The program is not neglectful of the many
physical problems that may arise in the course of
pregnancy and it requires no extra expenditure of
time by the physician.

METHOD

This pilot study was undertaken in the out-patient
clinic of the Department of Obstetrics and Gyne-
cology of the U.C.L.A. School of Medicine. Twenty-
one experimental subjects and 48 controls were
included, unselected except for the following cri-
teria: (1) No overt psychiatric disorder was present;
(2) the subjects had reasonable facility with and
comprehension of the English language; and (3)
they were willing to participate.

The subjects were divided into three groups of
seven on the basis of similarity of trimester. At
their first visit to the clinic a history was taken and
a physical examination carried out by a medical
student and an attending obsetrician. Then the
patients were given appointments to the first group
meeting. Routine laboratory work, immunizations,
and Mantoux testing were done at this time. One-
hour meetings were held twice a month in a con-
ference room equipped with a one-way mirror and
microphones for purposes of recording the discus-
sion. Before each meeting, urinalysis was carried
out and weight and blood pressure were recorded
by nurses.

At the first meeting the patients were informed
that they had been arbitrarily assigned to us for
their prenatal care and that we chose to meet in a
group setting in order to discuss together problems
common to pregnancy. We did not identify our
groups as experimental. In order to lessen differ-
ences between persons in the experimental group
and the controls, we encouraged participation in our
regular evening educational lecture-film series which
were available to all our obstetrical patients. Refer-
rals to neighboring Y.W.C.A. courses were given
to those expressing interest in natural childbirth
training; participation in those courses was neither
encouraged nor discouraged. Individual appoint-
ments with the obstetrical resident were made at

TABLE 1. — Total Hours Spent by Physician and by Patient in
Group Program as Compared with the Usual Clinic Program .

Usual Program Croup Program

Month of No. of Time in No. of Time in

Pregnancy Visits Minutes Visits Minutes

3rd; first visit.... 1 60 1 60

4th 1 10 2 120

5th 1 10 2 120

6th 1 10 *2 120

7th 2 20 2 120

8th 2 20-2 120

9th 4 40 *2 120

Total visits and — — - —

hours 12 2 hr. 50 rain. 13 13 hr.

Resident physician

Total hours .... 19 hr. 50 min. 15 hr. 20 min.

* 10 minute visit with physician.

approximately 24 weeks and again at 37 weeks.
These were held in the regular obstetrical clinic
examining rooms and the usual prenatal examina-
tions were performed.

Each of the bimonthly group sessions was attended
by an obstetrical resident, a psychiatric resident and
two nursing instructors. When guests were present
in the adjoining observation room their presence
was discussed and permission was obtained for the
use of the microphones. Topics were spontaneously
introduced from the group. The participants were
encouraged to answer the questions of others in the
group except when an authoritative reply was ex-
pressly asked of the physician. Occasionally, on the
initiative of the resident or patient, other individual
appointments were arranged as indicated. There was
no evidence that this occurred any more frequently
than it did with the control group. Although the
physician-patient relationship was more intimate
and intense, it did not result in appreciably greater
demands on his time than were made in the routine
clinic program.

Table 1 shows a comparison of actual hours spent
by physician and patient in the group program and
in the usual clinic program.

TESTS AND RESULTS

Psychological testing was done ( 1 ) to describe the
patient groups, (2) to record their attitudes toward
pregnancy,* and (3) to evaluate changes in morale
and in attitudes as a part of pregnancy and as a
result of the group sessions.

Fifty-one subjects completed the Shipley Institute
of Living Scale, the scores of which were converted
to estimated scores on the Wechsler Adult Intelli-
gence Scale.29 The average estimated Wechsler
intelligence quotient was 109, somewhat above the
adult population average. There were only small,
nonsignificant differences between the experimental

♦References 18. 22, 25-28, 35, 36.

282

CALIFORNIA MEDICINE

and the control groups and between the primiparous
and multiparous patients.

Forty-two patients completed the Minnesota Multi-
phasic Personality Inventory (MMPI) early in their
clinic contacts.15 On the eight major psychopathol-
ogy scales, the group averages were approximately
one-half to one standard deviation in the pathologi-
cal direction from the adult normal average.34 An
overall 45 per cent had one or more scores in the
pathological range, as contrasted with from 15 per
cent to 20 per cent pathological profiles among
unselected, non-psychiatric adults. About one-third
of the patients showed mild to moderate sociopathic
trends, suggesting traits of nonconformity, rebellion
and lack of self-restraint or inhibition. (Perhaps
inhibited and particularly modest women avoid such
a teaching clinic.) A smaller subgroup had profiles
indicating mild depressions, and the other profiles
were of varied types. There was a slight but sig-
nificant tendency for the multiparous patients to
have more pathological profiles, although this was
not concentrated in any area of psychopathology.
Postnatal testing was not sufficiently complete to
show clear trends.

An inventory of 104 True-False items pertaining
to pregnancy, childbirth and related attitudes was
developed. Sixty-seven women completed this form
at or shortly after their first clinic contact, including
both treatment group patients and controls.

Several of the items reflected a very positive
interest in discussing personal problems with their
physician. Ninety-five per cent responded “True”
to the statement, “Talking about my worries and
fears makes me feel much better.” Eighty-seven per
cent felt their physician was interested in them as a
person, and only 9 per cent were afraid that the
physician would think less of them if they talked
about their fears. Sixty-three per cent explicitly
agreed, “I would feel comfortable telling my doctor
my personal problems.”

Among these women 56 per cent reported they
would like to go through “natural childbirth” and
71 per cent wanted to be awake when their baby
was born. Sixty-three per cent felt a husband should
stay with his wife throughout labor, and to the item,
“I think that if both husband and wife wish it, the
husband should be allowed to watch the delivery,”
89 per cent answered “True.”

In comparing the answers of the primiparous pa-
tients with those of the multiparous, more of the
latter were unhappy about being pregnant. This
was reflected in the attitude on such items as : “Most
women are happy to be pregnant”; “Early in the
pregnancy, losing the baby would have been OK in
some ways”; “I wish my husband knew what it
was like to be pregnant.”

To further analyze these items, nine of the obste-
tricians were asked to answer the 104 items “as
you would expect an average pregnant woman to
answer them.” Four of these men were members of
the staff and five were residents. They were con-
sistently in error on only 20 per cent of the items —
a high accuracy compared to many response predic-
tion studies. Their errors were very largely among
items reporting fears, inhibitions and frustrations,
where they expected the negative feelings to be
consistently expressed, but they were not. These
included such feelings as fear of childbirth, of losing
the baby or that the baby would be abnormal,
resentments of the husband, and fear of losing one’s
figure. It is an open question whether the women
were covering over these feelings or actually were
not distressed by them as consistently and as in-
tensely as expected.5’12,18

Where a majority of the staff predicted one answer
(True or False) and the residents predicted the
opposite, the staff was right 31 times of 34. This
would directly suggest that one increasingly learns
these patient attitudes with continuing experience.
The point offered here is that group sessions such
as were held in this project offer an ideal situation
to learn and understand these patient attitudes.

COMMENT

In evaluating the results of our experience we
felt that the experimental sample was too small to
offer a sound basis for broad generalization. Never-
theless, a number of our subjective impressions
seem to deserve mention.

The concept of the “ideal pregnant woman,” as
proffered by theoretically oriented investigators,
implies that significant anxieties in pregnancy are
pathological.4 12 Our experience, corroborating the
writings of others,* suggests that “normal” pregnant
women have many anxieties; the extent and univer-
sality of anxieties are greater than we had expected.

Multigravid patients, in contrast to prevailing
opinion, are equally in need of emotional support
during pregnancy, for often the experiences of previ-
ous pregnancy seem to enhance rather than diminish
anxiety.

The work of Bibring suggests that much of the
florid psychopathologic manifestations of parturi-
ents is limited to the pregnant state. This might be
made analogous to other stressful periods in the
emotional growth of the individual (adolescence,
menopause). One might argue that this emotional
stress is usually handled by the natural “healing
processes” inherent in the individual, and that there
is no need for assisting these processes with
psychotherapy, since the effort might aggravate emo-

*References 5, 8, 18, 20, 24.

VOL. 97, NO. 5 • NOVEMBER 1962

283

tional conflicts which might better be left undis-
turbed. It was not our impression that the group
method aggravated psychopathologic states; rather,
it clearly seemed to relieve the existing anxiety.
An interesting but technically difficult study to un-
dertake would be one wherein psychological exam-
inations could be performed on a series of pregravid
patients who would then serve as their own controls
during a subsequent pregnancy. This might lead
to the documentation of patterns of profile shift in
reaction to pregnancy, about which the authors could
only speculate at this time.

Fear of pain, mutilation and possible death, loss
of self control, changes in body image and bodily
sensations, the possibility of a defective child and
relationships with physicians, nurses and hospitals
were major sources of anxiety expressed in the
group sessions. Preexisting conflicts with parents,
husbands and other authority figures frequently ap-
peared to be exacerbated by the demands of preg-
nancy. Other sources of anxiety, rarely discussed,
concerned sexual relationships, contraception, guilt
and resentments toward medical personnel.

The manifestations of anxiety were predominantly
depression32 and somatic complaints. These symp-
toms appeared coincidentally with periods of emo-
tional stress and seemed to remit coincidentally with
the resolution of emotional conflicts.

We began the meetings with set agenda and vari-
ous other formal approaches which we soon recog-
nized as manifestations of our own anxiety. With
additional experience and an awareness of the
gradual formation of a group identity, we were able
to permit the patients to discuss topics of greatest
importance to them. Our subsequent activity was
only to stimulate the discussion and to moderate it
as necessary. The patients too, at first, were anxious
about the meetings. The majority, however, soon
became comfortable, enthusiastic and cooperative.
In some, significant changes in attitudes were ap-
parent, with considerable reduction of preexistent
fears, a mature acceptance of responsibility of
motherhood and a realistic awareness of psychic
causation of various somatic symptoms. A few pa-
tients remained uneasy and unenthusiastic through-
out the period of prenatal care. These women
seemed to be those who were either inherently sus-
picious and defensive or who had developed a
life-pattern of dealing with emotional stresses by
somatization. To these women our attitude that
emotional stresses could be pertinent to their phys-
ical wellbeing was antithetical. It appeared never-
theless that they experienced some diminution of
their anxieties as pregnancy progressed, and they
certainly stimulated the groups to lively controversy
over the issues that were stressful to them.

Discussion with the participating nurses after the
group sessions revealed the presence of a strong
rapport between patients and nurses that differed
somewhat from the relationship of the patients to
the physicians.33 This observation is, of course, not
unique to this experimental situation and is probably
related to both the difference in sex and the different
roles the patient assigns to those who undertake her
care. An awareness of this rapport and its source
suggested that we utilize the nurses in an active
therapeutic role within the group structure. Their
presence subsequently served as an additional source
of information and they provided critical observa-
tions to evaluate the group processes. The ex-
perience afforded the nurses a greater amount of
intellectual stimulation than that ordinarily present
in routine clinic care and tapped an otherwise dor-
mant source of therapy.

^ As a training device we feel such a program
offers many advantages not present in more didactic
settings for the teaching of psychiatric skills. It
entails no further time expenditure on the part of
an already busy obstetrical resident. It enhances the
working rapport of the participating disciplines and
the primary emphasis upon patient care. Of addi-
tional benefit to the psychiatric resident is the
opportunity to deal with “normal” subjects and to
practice preventive psychiatry. The obstetrical resi-
dent under guidance gradually loses his sense of
discomfort, usually present in his dealing with psy-
chosomatic disease, and can begin to handle such
problems with greater skill and understanding
through repeated exposure. We believe that either
resident, alone, could conduct the meeting as a result
of the experience gained, and that an obstetrician
with psychiatric orientation would feel quite com-
fortable in the group atmosphere.

The expedient alleviation of emotional problems
through group psychotherapy is well known in fields
of medicine other than obstetrics. 6,14,23,30 Its effi-
ciency in helping small groups of patients with
common problems has been demonstrated in psychi-
atric disorders and psychosomatic conditions. From
the limited experience herein described, utilizing it
in a prenatal program seems to us quite promising.

U.C.L.A. School of Medicine, Los Angeles 24 (Golden).

REFERENCES

1. Asch, S. S. : In Medical, Surgical and Gynecological
Complications of Pregnancy, edited by Guttmacher and Ro-
vinsky, Williams & Wilkins Co., Baltimore, Md., 1960.

2. Balfour, Sclare A.: Psychiatric aspects of pregnancy
and childbirth. Practitioner, Lond., 175(1046) :146-54, Au-
gust 1955.

3. Ball, T. L. : The Psychoprophylactic Preparation of
Pregnant Women for Childbirth in the U.S.S.R.; Transac-
tions of the N. Y. Acad. Sci., Ser. II, Vol. 22:8, June 1960.

4. Benedek, Therese: Psychosexual Function in Women,
The Ronald Press Co., New York, 1952.

284

CALIFORNIA MEDICINE

5. Bibring, G. L. : Some considerations of the psychologi-
cal processes in pregnancy, The Psychoanalysis of the Child,
XIV, International Universities Press, 1959.

6. Bronner, A.: Observations on group therapy in private
practice, Am. J. Psychotherapy, 8:55-62, 1954.

7. Caplan, G.: Mental hygiene work with expectant
mothers — A group psychotherapeutic approach, Mental Hy-
giene, 35:41-50, January 1957.

8. Chertok, L. (Translated by Leigh, 1).) : Psychoso-
matic Methods in Painless Childbirth, Pergamon Press,
London, 1959.

9. Corsini, R. J.: Methods of Group Psychotherapy. Mc-
Graw Hill, 1957.

10. Daly, M. J., Winn, H., Hoffman, F. : An approach to
teaching obstetric-gynecologic residents the emotional as-
pects of their specialty, Amer. Coll. OB. Gyn. meeting,
April 1961.

11. Davidson, H. B. : Psychosomatic aspects of obstetrics,
J. Internat. Coll. Surgeons, 21(1:11:106-12, January 1954.

12. Deutsch, Helene: Psychology of pregnancy, labor and
puerperium. In: Green, J. P. Obstetrics. 11th edition, Phili-
delphia, Saunders, 1955, Chapter 25.

13. Dyer, I.: A recipe, Am. J. Obst. Gyn., 81:833, May
1961.

14. Harris, H. I.: Efficient psychotherapy for the large
outpatient clinic, N.E.J.M., 221:1-15, 1939.

15. Hathaway, S. R., and McKinley, J. C. : The Minne-
sota Multiphasic Personality Inventory Manual (Revised),
The Psychological Corporation, New York, 1951.

16. Hurvitz, N., and Berko, R.: Group counseling in pri-
vate obstetric practice, Obs. and Gynec., 16:6, December
1960.

17. Kartchner, F. D.: Active participation in childbirth:
A psychosomatic approach to pregnancy and parturition,
Am. j. Obst. Gyn., 75:1244-254, 1958.

18. Klein, H. R., Potter, H. W., and Dyk, R. B. : Anxiety
in Pregnancy and Childbirth, Hoeber, New York, 1950.

19. Kroger, W. S.: Psychosomatic aspects of obstetrics
and gynecology, Obst. Gyn. N. Y., 3(5) :504-16, May 1954.

20. Newton, N.: Maternal Problems, Paul B. Hoeber Co.,
N. Y„ 1954.

21. Parks, J.: Emotional reactions to pregnancy, Am. J.
Obst. Gyn., 62:339-45, August 1951.

22. Pleshette, N., Asch, S. S., and Chase, J.: A study of
anxieties during pregnancy, labor, and early and late puer-
perium, Bull. N. Y. Acad. M., 32(6) :436-55, June 1956.

23. Pratt, J. H., Johnson, P. E. (Editors) : A Twenty
Year Experiment in Group Therapy, New England Medical
Center, Boston, 1950.

24. Read, G. D.: Childbirth Without Fear, 4th Ed., Har-
per, New York, 1944.

25. Scott, E. M., and Thomson, A. M.: A psychological
investigation of primigravidae. I. Methods, J. Obst. Gyn.
Brit. Empire, 63(3) :338-43, June 1956.

26. Scott, E. M., Illsley, R., and Thomson, A. M.: A psy-
chological investigation of primigravidae. II. Maternal social
class, age, physique and intelligence, J. Obst. Gyn. Brit.
Empire, 63(3) :338-43, June 1956.

27. Scott, E. M., and Thomson, A. M.: A psychological
investigation of primigravidae. 111. Some aspects of maternal
behaviour, J. Obst. Gyn. Brit. Empire, 63(4) :494-501, Aug.
1956.

28. Scott, E. M., and Thomson, A. M.: A psychological
investigation of primigravidae. IV. Psychological factors
and the clinical phenomena of labour, J. Obst. Gyn. Brit.
Empire, 63(4) : 502-8, Aug. 1956.

29. Senes, L. K., and Simmons, H.: The Shipley-Hartford
scale and the Doppelt short form as estimators of W.A.I.S.
I.Q. in a state hospital population, J. Clin. Psychol., 1959,
Vol. 15, pp. 452-53.

30. Slavson, S. R.: The Fields of Group Psychotherapy,
International University Press, Inc., New York, 1956.

31. Straker, M.: Psychological factors during pregnancy
and childbirth, Canad. M. A. J., 70:510-14, May 1954.

32. Tobin, S. M.: Emotional depression during pregnancy,
Obst. Gyn., N. Y„ 10(6) :677-81, Dec. 1957.

33. Unpublished manuscript — Ringholz, Deck, Golden,
Pion, Caldwell.

34. Welsh, G. S., and Dehlstrom, W. G.: Basic Readings
on the M.M.P.I. in Psychology and Medicine, University of
Minnesota Press, Minneapolis, 1956.

35. Winokur, G., and Werboff, J.: The relationship of
conscious maternal attitudes to certain aspects of preg-
nancy, Psychiat. Quart. Suppl., 30:61-73, 1956.

36. Zemlick, M. J., and Watson, R. I.: Maternal attitudes
of acceptance and rejection during and after pregnancy,
Am. J. Orthopsychiat., 23:570, 1953.

VOL. 97, NO. 5

NOVEMBER 1962

285

Hay Fever

A Comparative Clinical Evaluation of Treatment with Aqueous
Pollen Extracts, Alum-Precipitated Pyridine Pollen Extracts
and Aqueous Pollen in Oil Emulsions

M. COLEMAN HARRIS, M.D., San Francisco

Currently there are three kinds of preparations
used in injection therapy of seasonal allergic rhinitis
due to pollen — aqueous pollen extracts, alum-pre-
cipitated pyridine pollen extracts, and the aqueous
pollen in oil emulsions employed in the so-called
“respository” treatment.

Aqueous Pollen Extracts

Subcutaneous injection treatment with the aque-
ous pollen extracts for the relief of hay fever is the
oldest and most widely used. It is considered effi-
cacious and, except for a constitutional reaction
which may occur if an improper dose is given, is
without danger in administration. Aqueous pollen
extracts can be easily made in one’s own office
laboratory or can be obtained from commercial
sources. Treatment is usually prophylactic or pre-
seasonal, although sometimes these preparations are
used during the height of the hay fever season for
amelioration of symptoms.

Hyposensitization is brought about by a series of
subcutaneous injections of increasing amounts of the
specific pollen allergens to which the patient is clin-
ically sensitive. However, exactly how hyposensitiza-
tion is accomplished by this means has never been
adequately explained. One theory is that the injec-
tion of potent specific allergens calls forth the produc-
tion of blocking, neutralizing or immune antibodies.
The antibodies are relatively heat stable and do not
have the property of sensitizing the skin of a normal
individual. They compete with the skin-sensitizing
antibodies in uniting with the antigen without releas-
ing the noxious chemicals that produce the allergic
reaction. Since it has never been unequivocally
proved that there is a correlation between clinical
improvement in the patient and the titer of the im-
mune blocking antibodies in the serum, it is proba-
ble that some other mechanism is at work either in
place of, or in addition to, that of blocking antibody
formation.

Presented before the Section on Allergy at the 91st Annual Session
of the California Medical Association, San Francisco, April 15 to 18,
1962.

• Three different types of pollen extracts are
currently being used in the prophylactic treat-
ment of hay fever. A comparative clinical study
of their efficacy reveals that all are about equally
efficacious. The alum-precipitated pyridine pol-
len extracts may be slightly better. Since only
14 to 16 injections are required for prophylactic
treatment, they may well replace the older aque-
ous pollen extracts, 20 to 35 injections of which
are usually necessary to provide relief.

The aqueous pollen in oil repository method
of treatment needs only one to four injections
for comparable results, but this so-called “one-
shot” treatment can only be administered by one
who is trained in emulsion therapy and has come
to know by experience the proper maximum
dose.

Alum-Precipitated Pyridine Pollen Extracts

Treatment with alum-precipitated pyridine pollen
extracts is being used by a limited number of aller-
gists, mostly experimentally. As with the aqueous
pollen solutions, the injections are administered sub-
cutaneously in a series of gradually increased doses.
The treatment is primarily prophylactic. These ex-
tracts are not simple to prepare and are not currently
commercially available. A laboratory with adequate
ventilation is necessary to get rid of the especially
noxious odor which arises from the pyridine used
in preparing them. The alum-precipitated pyridine
pollen extracts used in the present study were pre-
pared by Margaret Strauss of the New York Uni-
versity Hospital Allergy Laboratory, as follows : The
extracting fluid consisted of one part pyridine and
one part 0.3 per cent sodium carbonate solution.
Non-defatted pollen was thoroughly mixed with a
specified amount of this fluid and the mixture was
allowed to stand for three days in a cool room, after
which the liquid was filtered from the solids and then
was Seitz-filtered for sterilization. Next, under sterile
conditions, one part of sterile distilled water was
added to one part of the pyridine-bicarbonate pollen
extract, the mixture being stirred constantly as this
addition was going on. Then one part of sterile 2.0
per cent potassium aluminum sulphate in one-fourth
normal sulphuric acid was added. This formed a

286

CALIFORNIA MEDICINE

precipitate. After standing overnight, the mixture
was centrifuged and the supernatent solution dis-
carded. The residue was washed four times with
large quantities of sterile saline solution, sterile glass
heads being used to separate the particles of the pre-
cipitate and to facilitate washing. The final volume
of the suspension was then made up to the initial
volume with sterile saline solution. A protein nitro-
gen determination was run on this final sterile
product.

Advantages claimed for these extracts are:

1. All of the original fractions in the pollen grains
are incorporated in the extract. This includes the
oil fraction which some investigators insist contains
an allergically active constituent.

2. The suspension is slowly absorbed, as has been
shown by passive transfer studies. Thus, local irri-
tation and swelling at the sites of the injections are
avoided and there is less likelihood of constitutional
reaction.

3. Because of slow absorption, fewer injections
are required to maintain the patient’s optimum dose.
An obvious and recognized disadvantage of these
extracts is that they cannot be used for testing pur-
poses.

Aqueous Pollen in Oil Emulsions

Repository injection treatment of hay fever with
an aqueous pollen in oil emulsion has received con-
siderable attention in the lay as well as the scientific
press. The fact that only a very limited number of
injections are said to be necessary for hay fever
protection has made this form of treatment desir-
able, especially in the opinion of the patient. Al-
though the method is currently being used by an
increasing number of allergists throughout the
United States, the emulsions must be made with care.

The object is to produce a water in oil emulsion
in which the water phase is aqueous pollen extract.
The tiny droplets of aqueous pollen extract are con-
tained within an external phase of mineral oil. kept
in suspension by electrical charges set up during
the process of emulsification and discharged slowly
into the general circulation at intervals which have
been determined by laboratory experiment.

The preparations are made by using a non-ionic
emulsifier to aid the emulsion of aqueous pollen
extracts with a specially prepared very light mineral
oil. Since the introduction of this form of treat-
ment, several different proportions of the oil and
emulsifier have been suggested, as well as varying
the amounts of the aqueous pollen extract. These
variables, as well as those having to do with the
means of producing the emulsion, pose difficulties
for physicians wishing to use this method of therapy.

Many of the arguments that were initially ad-

vanced against the use of aqueous pollen in oil
emulsions have been answered, but many objections
remain : There is no standardized method of pre-
paring the emulsion; the formula has been repeatedly
changed and modified; the technique of examining
the emulsion after preparation to determine if it is
a good emulsion requires training in microscopy;
there is no fully accepted method of determining the
patient’s optimum dose; care must be taken in ad-
ministering emulsion deep subcutaneously, lest the
emulsion escape to the dermis; there is suspicion
that the inadvertent injection of emulsified extracts
containing allergens to which the patient is not
sensitive may result in the production of new imme-
diate or delayed sensitivities. The question of car-
cinogenicity of mineral oil is an academic one and
there is no certain answer. Millions of emulsion in-
jections have been administered in a period of 20
years with no reports of carcinoma having been
produced. Mineral oil has been used orally and rec-
tally, obviously absorbed by lacteal vessels, for a
long time with no carcinogenicity reported. How-
ever, should a case be reported tomorrow, the
problem would then cease to be academic.

In preparing 100 cc. of the oil phase of the emul-
sion in this study, 35 ml. of Arlacel® A* which is
a non-ionic emulsifier, and 65 ml. of Drakeol®
6VRt which is a mineral oil, were used. To this was
added 0.02 ml. of Tween 80*. A hemoglobin pipette
was used to measure this small amount. Tween 80 is
a surfactant which was added to ease the work of
emulsification and to lessen the milling and homog-
enization which frequently occurs with water in oil
emulsions.

Equal amounts of the water phase, which was an
aqueous pollen extract, and the oil phase were em-
ployed in preparing the emulsion. No more than 4.0
ml. was prepared at any one time — 2.0 ml. of the oil
phase (the Arlacel-Drakeol mixture) and 2.0 ml. of
the aqueous phase (the aqueous pollen extract).
Emulsification was carried out by means of the Con-
scot Emulsifiert for a period of at least 25 minutes,
as advised by the manufacturer.

The Conscot Emulsifier is a power-driven machine
providing 12 strokes per minute and delivering al-
ternate thrusts to the plungers of two interchangeable
10 cc. Luer Lock syringes. The syringes are con-
nected to each other by a double-hubbed 18-gauge
needle, in the middle of which an emulsifying valve
has been placed. This emulsifying valve contains a
meshed disc with perforations of 0.0024 of an inch
or 62 microns. As the water and oil mixture placed

*Arlacel A and Tween 80 were procured from the Chemicals Divi-
sion of the Atlas Powder Company, Washington, Delaware.

tDrakeol 6VR was procured from the Pennsylvania Refining Com-
pany, Butler, Pennsylvania.

tThe Conscot Emulsifier is manufactured by the Conscot Company,
Rockaway, New Jersey.

VOL. 97. NO. 5 • NOVEMBER 1962

287

in one of the syringes is passed to the other and back
and forth by action of the motor, shearing takes
place. In addition, due to the turbulence of the flow,
electrical charges are produced which result in the
aqueous pollen mixture surrounded by a film of light
oil. Although presumably suitable for repository
injection, the emulsion was examined to make sure.
This was done by placing a drop of the prepared
emulsion on the surface of water in a beaker. If it
did not retain its sphericity it was considered a poor
emulsion and discarded. A more exacting test was
used on all emulsions before use. That was the care-
ful microscopic examination of a drop of the
prepared emulsion. With the high-power lens the
emulsion was examined for homogenicity and uni-
formity of globule size. Just before administration,
the emulsion was placed in the Conscot machine for
an additional ten minutes.

One milliliter was the amount administered in a
dose that duplicated the optimum dose reached by
the patient the previous year with aqueous pollen
extract therapy. In this kind of therapy, as with the
other two previously described, no completely accept-
able explanation has been advanced with regard to
the mechanism by which the water in oil emulsion
produces immunity.

Clinical Evaluation

A clinical evaluation and comparison of results of
parenteral prophylactic treatment of hay fever is
difficult, for in this disease there is a preponderance
of subjective symptoms over objective findings. It is
necessary to rely upon the patient’s ability to recall,
estimate and keep an accurate record of the severity
and frequency of symptoms. In evaluating results,
the age and sex of the patient, his work, play or
exercise, environmental influences, emotional prob-
lems, climatic changes, as well as fluctuation of the
amount of circulating pollen in the air from day to
day and from season to season, must be taken into
consideration. In addition, there are psychological
factors at work. Some patients are hopeful when
they are introduced to a new form of treatment and
in their reports tend to minimize their symptoms;
others are apprehensive and are apt to magnify
them. Some physicians are enthusiastic over every
new therapeutic procedure; others are prone to criti-
cize a new method or departure from the type of
therapy they have been accustomed to use. These
factors all affect the patient’s subjective response.

In order to circumvent and prevent or minimize
biased reports on a new drug or new method of
treatment, double blind studies using placebos have
been demanded of clinical investigators. Some such
studies are of value, particularly in evaluating drug
efficacy, but the variables of age, sex, work, play,
exercise, environmental influences and emotional

upsets, not to mention the reliance the physician
must place on the intelligence of the patient and the
exactitude with which he regards and records his
discomfort, still remain. That there are no two peo-
ple exactly alike who can be evenly matched and
kept in the same environment is self evident. That
physicians attempt to guess, consciously or uncon-
sciously, which is the placebo and which is not,
thus becoming prejudiced in one way or the other,
is natural. In the last analysis, one must rely upon
the credulity of the patient and the exactness of his
records. An additional objection to using placebos
in determining results of hay fever treatment, par-
ticularly when using aqueous pollen in oil emulsion
therapy, is based on the fact that the oil phase of the
emulsion is an adjuvant. Although it is not entirely
proved, some investigators believe or suspect that
mineral oil, in itself an incomplete adjuvant, in-
creases the antibody titer in patients who have
received antigen injections even several years previ-
ously. Since all of the patients in this study who
received aqueous pollen in oil repository treatment
had had conventional antigen injection treatment
previously, the injection of an antigen-free emulsion
could hardly have been considered a placebo.

For these reasons no double blind studies were
employed in evaluating the results of treatment with
the aqeuous pollen extracts, the alum-precipitated
pyridine pollen extracts and the aqueous pollen in
oil emulsions. The patients were taken in consecu-
tive order as they came in to be treated. In assessing
results at the end of the hay fever season, I inter-
rogated the patients with as much objectivity as
possible. The patients were urged to give an un-
biased, unprejudiced and honest report. Some of
those who received aqueous pollen therapy and some
who received alum-precipitated pyridine pollen in-
jection therapy had never been treated before with
prophylactic pollen injections. All of those who re-
ceived the aqueous pollen in oil repository treatment
had been treated previously with aqueous pollen in-
jections. Since there may be a “holdover” from
treatment in a previous year, the results in each
group were tabulated separately.

Results with Aqueous Pollen Injection Therapy

Results reported by 175 patients treated prophy-
lactically against spring (grass) hay fever in 1961
with aqueous pollen extracts were as follows:

A — One hundred sixty patients previously treated for one
or more years — Excellent or good, 128 cases or 80 per cent;
fair, 18 cases or 11.2 per cent; poor, 14 cases or 8.8 per cent.

B — Fifteen patients with no previous treatment — Excel-
lent or good, 9 cases or 60 per cent; fair, 4 cases or 26.5 per
cent; poor, 2 cases or 13.5 per cent.

Good to excellent responses indicated that the
patient had no symptoms, or if he sneezed a few
times or had mild itchy eyes during the hay fever

288

CALIFORNIA MEDICINE

season, the symptoms were so mild that no addi-
tional medication was necessary. A fair response
indicated that the patient had symptoms at the height
of the hay fever season which required some addi-
tional medication such as antihistamines. Poor re-
sults indicated that considerable medication was
necessary for relief and that the injection treatment
afforded very little, if any, relief.

Results with Alum-Precipitated Pyridine
Pollen Injection

For 57 patients treated prophylactically against
spring (grass) hay fever in 1961 with alum-pre-
cipitated pyridine pollen extracts results were as
follows:

A — Forty-seven patients previously treated for one or
more years with aqueous pollen extracts — Excellent or good,
44 cases or 94 per cent; fair, 1 case or 2 per cent; poor,

2 cases or 4 per cent.

B — Ten patients with no previous treatment — Excellent to
good, 7 cases or 94 per cent; fair, 1 case or 3 per cent;
poor, 2 cases or 20 per cent.

Dr. Merle Moore of Portland, Oregon, treated a
similar but slightly larger series during the spring
of 1961. The only difference in his technique was
that instead of interrogating the patients himself, he
had a third party question them and record the
results, thus eliminating the possibility of subcon-
scious bias. Dr. Moore’s results were as follows:

A — Ninety patients previously treated for one or more
years with aqueous pollen extracts — Excellent to good, 74
cases or 82 per cent; fair, 13 cases or 15 per cent; poor,

3 cases or 3 per cent.

B — Thirty patients with no previous treatment — Excel-
lent to fair, 25 cases or 83 per cent; fair, 3 cases or 10 per
cent ; poor, 2 cases or 7 per cent.

Results with Aqueous Pollen in Oil Repository
Injection Therapy

One hundred thirty patients treated six to eight
weeks before the 1961 spring (grass) hay fever sea-
son with a single injection of an aqueous pollen in
oil emulsion extract reported results as follows:

Excellent to good results, 103 or 79 per cent; fair, 14, or
11 per cent; poor, 13, or 10 per cent.

It should be reemphasized that all of these patients
had received previous hay fever injection therapy
with aqueous pollen extracts and that their probable
optimum dose had been determined.

REACTIONS

In the 175 patients treated with aqueous pollen
extract no reactions occurred with the exception of
soreness of the arm at the injection site in a few
cases. The same was true of the 177 patients treated
with alum-precipitated pyridine pollen. However,
in the group of 130 patients treated with the aqueous
pollen in oil emulsion, 37 (28 per cent) had reac-

tions of various types, ranging from mild soreness
at the injection site for periods of a day or two to as
long as three months, to the formation of nodules
and abscesses. Constitutional reaction occurred in
one case.

It h as been suggested that the side effects or com-
plications associated with aqueous pollen in oil
emulsion injection therapy are due to the use of an
improperly prepared emulsion, or to the formula
used or to the manner in which the injection is ad-
ministered. However, the formula, the emulsifying
technique and the injection method used in this
study were the ones acceptable to most workers in
hay fever emulsion therapy.

COMPARISONS

Comparison of clinical results in the treatment of
hay fever is difficult and in some cases impossible.
In the first place pollen counts vary from one area
to another in the same city, winds change, some
patients are out of doors more than others, each
patient estimates his degree of suffering differently.
These are but a few of the factors that must be
taken into consideration. Other factors have already
been mentioned. Secondly, patients who have re-
ceived prophylactic injection therapy in previous
years may well have a “holdover” effect, and a com-
parison of the results in these patients with results
in patients who have had no previous prophylactic
therapy may be unfair. Nevertheless, bearing these
considerations in mind the data presented in Charts
1 and 2 are interesting.

In Chart 1, 80 per cent of patients who had never
previously received any form of prophylactic injec-
tion treatment are shown as having had good to
excellent results from the alum-precipitated pyridine
pollen injections, while results of that order were
reported for only 60 per cent of those treated with
aqueous pollen. The patients who received the aque-
ous pollen injections did better in the “fair” classi-
fication— 26.5 per cent in contrast to 10 per cent for
those treated with the alum-precipitated pyridine
pollen. In the “poor” category, there was little dif-
ference between the two types of treatment. It is
recognized that a further cloud upon the validity
of the comparison of these two groups is that there
were only 15 in one as against 40 in the other.

In Chart 2, data on results of all three forms of
treatment in all the patients treated are compared.

DISCUSSION

If any conclusion can be drawn from the com-
parisons available in the present study, it is that
alum-precipitated pyridine pollen prophylactic treat-
ment has a slight edge in efficacy of treatment, but
it probably is unfair to compare results with aqueous

VOL. 97. NO. 5 • NOVEMBER 1962

289

CHART 1

CHART 2

SPRING (GRASS) HAY FEVER SEASON- 1961
NONE OF PATIENTS HAD RECEIVED DESENSITIZATION
PROPHYLACTIC TREATMENT IN PREVIOUS YEARS.

100

GOOD TO
EXCELLENT

FAIR

POOR

- C

v\PARATIVE RESULTS BETWEE

1 AQUEOUS POLLEN

1 INJECTIONS (15 PA

■| ALUM PRECIPITATED

H PROPHYLACTIC INJ

TREATMENT WITH

PROPHYLACTIC

TIENTS) AND
PYRIDINE POLLEN
ECTIONS (40 PATIENTS) —

■

pollen extracts which have been in use for fifty
years with the results obtained by treatment with
alum-precipitated pyridine extracts, which are only
now being investigated, and with the even newer
aqueous pollen in oil emulsion therapy.

There is no doubt that both the alum-precipitated
pyridine extract and the aqueous pollen in oil emul-
sion possess an advantage — fewer visits to the phy-
sician’s office. If there is no danger to the patient
with these newer methods and the results are equal,
they will of course supplant the aqueous pollen in-
jections. The repository treatment requires from one
to four or five injections annually, depending upon
the patient’s sensitivities. The alum-precipitated py-
ridine method requires about 12 to 16 injections,

SPRING (GRASS) HAY FEVER SEASON- 1961

100

GOOD TO
EXCELLENT

FAIR

POOR

COMPARATIVE RESULTS BETWEEN T

REATMENT WITH

—

1 (175) PATIENTS

WWVJ ALUM PRECIPITATED PYRIDINE POLLEN

&VVVN PROPHYLACTIC INJECTIONS (177 PATIENTS)

■jj^B AND AQUEOUS POLLEN IN OIL REPOSITORY

—

n « ■

sometimes fewer. Apparently any number of anti-
gens can be included in the alum-precipitated
extract and the number of injections depends pri-
marily upon the degree of the patient’s sensitivity.
Aqueous pollen treatment usually requires 20 to 35
or more injections, depending upon the number of
the patient’s sensitivities and the degree.

In the series of cases reported, all patients were
given what was considered to be their optimum dose.
With aqueous pollen extract, the optimum dose was
determined by the degree of local reaction obtained
at the site of the injections and the relative freedom
of symptoms by the patient. A similar method was
employed to determine the optimum dose for the pa-
tients who received the alum-precipitated pyridine
pollen extract. Patients who received the aqueous
pollen in oil emulsion injection were given the op-
timum dose they had reached previously with aque-
ous pollen extract administration.

450 Sutter Street, San Francisco 8.

290

CALIFORNIA MEDICINE

Skin Closure

A Disposable Atraumatic Instrument for Office Procedures

MARTHE E. BROWN, M.D., and ADOLPH M. BROWN, M.D., Beverly Hills

Despite the increasing use of the hospital, even
for seemingly minor procedures, operations in the
office still make up a large part of the practice of
many physicians. The closure of small lacerations,
biopsy procedures, small tumor excisions and even
incision and drainage are more and more a part of
office practice — a convenience to the patient as well
as the physician. Want of means for painless, con-
venient, cosmetic closure of a wound or incision
makes hospitalization necessary for procedures that
otherwise could be done in a physician’s office.

While there are many ways to close a laceration
or surgical incision, almost all the usual ones have
some drawbacks. The use of interrupted sutures re-
quires needle, silk and other instruments, all of
which must he kept sterile. In many instances, only
one suture is needed, and the remaining material
is wasted. Using such suture material requires drap-
ing the area of operation with at least three sterile
towels to prevent contamination of the thread. Also,
sewing with a needle often necessitates local or even
general anesthesia.

Use of clips of the Michele type, although an im-
provement over the needle technique, has shortcom-
ings. Not only does applying them cause pain but
the large teeth of each clip often leave scars. An-
other drawback is that the saddle of these clips is
so high above the wound that it is almost impossible
to apply a pressure bandage, which often is needed.

A third way of skin closure commonly used in
office procedure is application of a butterfly band.
While easy to use, the adhesive rests on the top
layer of the skin, which is shed daily, the resultant
slippage reducing the needed traction at a time
when exact approximation of wound edges is most
important. Use of the butterfly also precludes the
proper eversion of the skin edges which is so impor-
tant for a cosmetic result.

In light of these difficulties, any otherwise accept-
able method which would afford ease of application
and a cosmetic result should be welcomed by physi-
cians who carry out surgical procedures in the office.

A new skin clip that provides accurate, cosmetic
skin closure with simplicity and speed has already
been reported.1'3 It has ultrafine spicules which

Submitted June 7, 1962.

From the Departments of Surgery and Pathology, The Mount Sinai
Hospital, Los Angeles 48.

• A disposable applicator with a suture clip
bearing unusually fine spicules, which can be
kept sterile in an envelope on an office shelf or
in a physician’s bag, facilitates the carrying out
of the cosmetic closure of skin lacerations and
incisions as an office procedure.

The spicules of the clips are so fine that they
cause practically no bleeding when they are
placed or removed. The needle-prick scarring
and the “ladder” pattern caused by the placing
of sutures with a needle are avoided.

make for application without pain, and when in
place it lies so flat that pressure dressings can be
applied neatly over it. After healing there is no
scarring at the points of penetration.

The Brown-Wood applicator used for placing
these clips was designed to hold ten clips and was
originally intended for use in the operating room
for major closures. Now the same principle has been
used in the development of a disposable applicator,
holding a single clip, which can be kept sterile in an
envelope on a shelf in the office or in a physician’s
bag.

As applied with the disposable applicator, the
clips bring the skin edges in gentle but accurate
approximation (Figure 1). At the same time, the
carefully calculated curvature of the penetrating
spicules brings about the proper skin eversion for
best cosmetic effect. The spicules are so fine that
the clip may be used upon the face. In use, the in-
strument is held almost horizontally over the wound.
Fine-toothed forceps or skin hooks rarely are neces-
sary. The clips, whose spurs are so fine that they are
almost invisible, go into the keratin easily. They
should be placed with the distance between the spur
and the line of closure the same on both sides. Then
gentle pressure on the compression arms of the dis-
posable applicator brings the limbs of the steel clip
inward and the skin edges into excellent approxima-
tion. The accurate obliquely curved spicules of each
clip ease the wound edges together into just the
proper degree of upward eversion and side by side
approach into intimate contact. It is not necessary
to push the wound edges together tightly. The slight
postoperative edema aids in the approximation
procedure. If more than one is needed, the clips
may be applied close together, overlapping like fish
scales (Figure 2) .

VOL. 97. NO. 5 • NOVEMBER 1962

291

Figure 1. — The approximation of the skin edges, using
the disposable plastic applicator — in this case to close
tlie skin after excision of biopsy specimen.

Figure 2. — If more than one clip is needed, they can be
overlapped.

In the manufacturing process the spicules of these
clips are sheared to points much sharper than those
made by the punching out method used in making
clips of other kinds (Figure 3). The spicules pene-
trate enough to hold firmly, yet with so little trauma
that local anesthesia is not necessary. Rarely does
bleeding occur at the site of penetration. The clips
are of stainless steel and have been tested against
oxidation in saline and in Ringer’s solution.

Figure 3. — Comparison of the spicules of the Michele-
type clip (right) with those of the Brown-Wood clip. The
sheared points and minimum penetration depth of the
latter clip are obvious.

Figure 4. — The thumb-operated forceps for ease of re-
moval of Brown-Wood clips.

There seem to be two contraindications to the
use of these clips: They should not be applied over
the eyelids because of the possibility that they might
fall into the eye, and they should not be used for
purposes of traction, since traction might disturb
the line of closure, with bad cosmetic result. If
traction is needed to relieve tension upon the skin,
as it may be in larger wounds, traction or anchor
sutures may be buried below the surface of the skin
before closure with the clips is commenced.

The clips are usually removed on the third day.
A simple thumb forceps remover, whose limbs are
inserted between the arms of the stainless steel clip
(Figure 4) is available for the purpose, but any
conventional clip-remover will do as well. Compres-
sion on the removal forceps spreads the points of
the clip apart, which withdraws them from the skin.
Rarely is there any bleeding on removal. No pin-
point scars remain, and no “ladder” marks as when
tight thread sutures are employed.

9735 Wilshire Boulevard, Beverly Hills (Brown, Adolph M.l.

1. Brown, A. M.: A new surgical skin suture clip for
wound approximation, Industrial Medicine and Surgery,
30:6, 223-234, June 1961.

2. Brown, A. M., and Marcus, P. M.: Cosmesis and speed
in wound closure; a new suture clip. Western J. of Surg.,
Obst., and Gynecol., 69:269-271, Oct. 1961.

3. Brown, M. E.: A dermatologic skin suture clip, Arch.
Derm., 84:663-666, Oct. 1961.

292

CALIFORNIA MEDICINE

Bronchographic Contrast Mediums

HOWARD F. MARTIN, M.D., Palo Alto, and LLOYD F. O'NEIL, M.D., Aurora, Illinois

Tiie bismuth subcarbonate insufflation techniques
devised by Jackson and Clerf and the barium sulfate
in mineral oil method of Lynah were generally
discarded soon after Forestier in 1925 summarized
his experiences with iodized peanut oil (LipiodoT: )
for bronchography. But iodized peanut oil and
iodized poppyseed oil (Iodochlorol®) have well-
recognized shortcomings, which has led to the trial
of a number of radiopaque materials for bronchog-
raphy, with variable success.

Insufflated powder is good for demonstration of
the trachea and major bronchi, hut it rarely shows
anything not seen with less risk by bronchoscopy.
Barium sulfate in oil is not readily eliminated from
the tracheobronchial tree, frequently acts as a for-
eign body and occasionally produces oil pneumo-
nitis. Other combinations of barium with iodized
oils or as collodial suspension (Celobar®*) 24 still
entail this possibility. Iodized peanut and poppyseed
oils are simple to use and usually result in adequate
bronchograms, but both tend to enter the alveoli
and require months or even years for complete
elimination. Oil pneumonitis is rare, but it has been
reported with these agents, particularly after over-
filling of a segmental bronchus.

Certain experimental agents such as Xumbra-
dil®t20 and Acmiodol®!15 have been less satisfactory
than Lipiodol and Iodochlorol due to low viscosity
and rapid alveolar filling. Other agents such as
cesium chloride22 entered the alveoli so rapidly as to
be useless unless mixed with carboxymethylcellulose,
but then became so irritating as to cause severe
injury to bronchial mucosa. Thorium dioxide (Thor-
otrast®)1 and Joduron B®8 also seem too irri-
tating. Some of the newer agents such as Bayer
1238 (Broncho-abrodil®) ,5,13 iodized benzoic ester
in peanut oil (Pulmidol®) ,16 and the aqueous sus-
pension of propyl-diol-diiodopyridone and diiodo-
pyridone (Hytrast®)17 seem quite promising, al-
though present reports are insufficient for dependable

Presented before the Section on Ear, Nose and Throat at the
91st Annual Session of the California Medical Association, San
Francisco, April 15-18, 1962.

’Celobar® is: Barium Sulfate (65.3 gm. per cent), Methylcellulose
(0.8 gm. per cent) in physiological saline.

tXumbradil® is: Solution of Diodon® (diethanolamine salt of
diiodo-pyriden-N-acetic acid) and sodium salt of cellulose glycolic
acid ether.

lAcmiodol® is 2-( 2,4,6-Triiodophenoxy ) propane, 27.0 per cent.
l-( 2.4,6-Triiodophenoxy) hexane, 29-2 per cent, Cottonseed oil,
43.8 per cent.

• In a study of 102 bronchograms for purposes
of comparing the contrast medium Viseiodol® (a
mixture of iodized peanut oil and powdered sul-
fanilamide) with Iodochlorol® (an iodized poppy-
seed oil), it was observed that Viseiodol is more
readily administered, produces better broncho-
grams with less alveolar filling and clears from
the lungs far more rapidly and completely than
does Iodochlorol.

Certain even newer highly promising agents
are available but specific results with them are
not included with this report.

Bronchography is a diagnostic procedure that
is contraindicated when the information to be
gained does not exceed the probable risk.

conclusions. These newest agents all seem to give
excellent contrast and are currently under investiga-
tion as to safety, route and rate of elimination,
alveolar fill and other important factors.

In the past ten years, three agents have come into
common use. Each gives good bronchograms, hut
not without definite drawbacks. The present litera-
ture usually discusses these agents: the propyl ester
of diodone in aqueous solution with sodium car-
boxymethylcellulose to increase viscosity (Aqueous
Dionosil®), the same ester in peanut oil (Oily Di-
onosil®), and a suspension of finely powdered
sulfanilamide in iodized poppyseed oil (Viseiodol®).
Varying ratios of Lipiodol® and sulfanilamide have
been studied7 and Oily Dionosil has been mixed with
sulfanilamide-neohydriol mixtures,14 but only the
routine forms of Dionosil and Viseiodol are per-
tinent to the present discussion.

Aqueous Dionosil. This material is water soluble,
the rapid elimination of the contrast dye is assured
and the agent quickly loses radiopacity. It appears
to be faster in bronchial filling, fills alveoli less and
radiographically clears faster than the other agents.
However, acute bronchitis or post-bronchogram py-
rexia is frequently reported with this agent.121819
Experimental studies of this material in rabbit lungs
show parenchymatous changes even four months
after its instillation for a bronchogram.2 The authors
of that study attributed the parenchymatous damage
to irritation by the carboxymethylcellulose vehicle.

Oily Dionosil. The peanut oil vehicle used in this
preparation seems to he eliminated by a combina-

VOL. 97, NO. 5 • NOVEMBER 1962

293

TABLE 1. — Study of Factors Affecting Adequacy of Two Contrast Media Used in Making Bronchograms

Contrast

Medium

Tracheobronchial

Demonstration

Alveolar

Filling

None

Radiopaque Residua After 24 Ho
Slight Moderate Much

urs

Very Much

Iodochlorol®

very good

none

.. 12

(102 patients)

good

slight

.. 26

fair

moderate

.. 29

poor

much

.. 28

inadequate

very much

.. 7

Visciodol®

very good

none

.. 17

2 •

(38 patients)

good

slight

.. 17

fair

moderate

.. 4

poor

much

.. 0

inadequate

very much

.. 0

tion of expectoration, swallowing and partial en-
zymatic hydrolysis.9,19 It seems less irritating than
Aqueous Dionosil, and pathologic studies have dem-
onstrated less tendency to granuloma formation
such as has been observed with plain Lipiodol.12
However, even when post-bronchogram x-ray films
show clearing of the radiopaque material, surgi-
cal specimens often reveal mucosal inflammatory
changes, free oil in the alveoli and intracellular oil
droplets.6'25 Studies with rabbit lungs showed oil
residua three months after instillation in 80 per cent
and after six months in 70 per cent of the rabbits,
with foreign body granuloma formation in most of
the animals. Despite these irritating properties,
this agent has been quite widely adopted because it
is relatively easy to use.

Visciodol. Since the radiopaque component of
Visciodol is oily and therefore is the relatively
non-absorbable portion of this material,3 and the
viscosity-increasing portion of the mixture — sulfa-
nilamide— is absorbable and then is excreted, it can
be assumed that radiographic clearing represents
elimination of sulfanilamide. There is the danger of
allergic reaction to sulfonamide as well as to iodine
and in certain cases the sulfanilamide has been
thought to have caused partial methemoglobi-
nemia.11 Nevertheless, as early as 1953, one group
of investigators reported over seven thousand Vis-
ciodol bronchograms without complication.21 This
agent has approximately three times the viscosity of
Lipiodol,4 and it rarely enters the alveoli except in
bronchiectatic regions. In general, it seems to be less
toxic than most other agents.10,23

Since some physicians still use the same Lipiodol
methed described in 1925, it was deemed worth while
to review the experiments which were the basis for
our changes five years ago. In this study, Visciodol
was compared with Iodochlorol as to adequacy of
demonstration of the tracheobronchial tree, ease of
employment, alveolar filling and post-bronchogram
residua. Technical errors also were analyzed in
terms of possible improvement of technique with
each agent.

Basic Technique

Regardless of the material used, the technique
was constant. Premedication and local anesthesia
were the same as for bronchoscopy. A Stitt broncho-
graphic catheter was inserted through the larynx
under indirect laryngoscopy, using a curved catheter
guide to facilitate control. Using a syringe connected
to the catheter by an appropriate adapter, the
bronchographic agent was injected under fluoro-
scopic control. During the injection, both the oto-
laryngologist and the radiologist were engaged in
observing the fluoroscopic screen so that the injec-
tion rate and the patient’s position were adjusted
to assure the filling without overfilling of each
bronchial segment. Inadequate anesthesia, delays
allowing loss of the effectiveness of anesthesia, lack
of cooperation by the patient and backflow of the
agent through the larynx were the major causes of
uncontrolled cough. This usually resulted in a poor
bronchogram and, with relatively free-flowing agents,
in excessive alveolar filling. Spot films were usually
taken during the fluoroscopy with the patient erect
and the x-ray apparatus at the routine 6-foot dis-
tance. Because the technique with children is some-
what different, no children were included in this
study.

Precautions

Even more than with bronchoscopy, bronchogra-
phy is contraindicated if the potential dangers equal
or exceed the probable benefits of this solely diag-
nostic procedure. The respiratory reserve must be
adequate. Severe dyspnea practically always presents
an undue risk. Sensitivity to the agents to be used
is a contraindication. Pulmonary secretions must
not be enough to prevent adequate anesthesia and
control of cough, to prevent adequate filling of the
tracheobronchial tree by the bronchographic agent
or to prevent adequate filling without causing dysp-
nea. Since the medical management of severe
suppurative bronchitis is essentially the same as for
bronchiectasis, the risk of bronchogram is not
entirely justified if suppuration is bilateral and not
amenable to surgical treatment.

294

CALIFORNIA MEDICINE

Figure 1. — Upper left, bronchograph taken with Iodochlorol as contrast medium. Upper right, 24 hours after
injection of Iodochlorol. Below, left and right, corresponding films (same patient ) with Visciodol as contrast medium.

Results

The present study includes all bronchograms per-
formed by the authors using Iodochlorol or Visci-
odol in adult patients at the University of Illinois
Hospitals during the two-year period from June 6,
1956, through June 4, 1958. This includes 102
bronchograms with Iodochlorol and 38 broncho-
grams with Visciodol. In 11 patients, for the purpose
of this study, the bronchogram was performed using
one of the two agents, and then, after an interval
sufficient for radiographic clearing of the agent from
the lungs as demonstrated by a new preoperative
x-ray film, another bronchogram was made, using
the other agent.

The general results are summarized in Table 1.
The judgments as to adequacy of tracheobronchial
demonstration, relative amount of alveolar filling
and radiopaque material residual after 24 hours,
were made by the authors, assisted by one of the

radiology staff. These judgments were made without
knowledge of the agent employed in any individual
bronchogram. Every effort was made to be objec-
tive, although admittedly this is at times difficult.
The illustrations (Figures 1 and 2) are from two
of the patients who had a second bronchogram with
the alternate contrast agent for comparison with
their first bronchograms.

Avoidable technical shortcomings brought to light
included :

• Inadequate demonstration of anterior segments
of lingula or of upper lobe segments due to inade-
quate attention to these areas during positioning of
the patient under fluoroscopic control.

• Inadequate anesthesia due to delay between an-
esthesia and carrying out of the procedure.

• Poor patient cooperation due to lack of explana-
tion of the procedure to the patient.

VOL. 97, NO. 5 • NOVEMBER 1962

295

Figure 2. — The bronchograph at upper left was taken with Iodochlorol and that at upper right was taken 24
hours later. In the lower films (same patient as above ) Visciodol was used and the interval was the same.

* Language difficulties making communication im-
possible.

• Incessant cough by one patient upon whom the
procedure probably should have been avoided in
view of this tendency.

In this series we noted no instance in which
Visciodol when employed according to directions
supplied by the manufacturer is any more difficult
to use than any other agent. On the contrary, its
slower rate of flow allowed better fluoroscopic con-
trol. An interesting observation with Visciodol was
that it appeared to clear in one or two days, with
the notable exception of areas of saccular bronchi-
ectasis, which often appeared prominently on the
24-hour follow-up films. It might be an interesting
point for further research to observe if residual
Visciodol in any other areas could possibly repre-
sent malfunction of ciliary activity.

No matter what agent is used, one of the com-

monest reasons for excessive alveolar filling appears
to be overfilling of the main bronchi. Twenty-five
cubic milliliters of Iodochlorol or 30 ml. of Visci-
odol is adequate for a bilateral bronchogram in the
average adult male, except where a large amount of
the agent enters saccular of cystic areas.

In none of the patients in the series was any local
or systemic reaction observed. In none was there
bronchial fistula or postoperative delay of healing
that could be attributed to the bronchogram.

1101 Welch Road, Palo Alto (Martin).

REFERENCES

1. Bickerman. H. A.: Exsufflation with negative pressure:
Elimination of radiopaque material and foreign bodies from
bronchi of anesthetized dogs, Arch. Int. Med., 93:698-704,
May 1954.

2. Bjork, L., and Lodin, H.: Pulmonary changes follow-
ing bronchography with Dionosil Oily, Acta Radiol., 47:
177-80, March 1957.

296

CALIFORNIA MEDICINE

3. Bovornkitti, S., Fantasuwan, P., Kangsadal, P.: Post-
bronchographic protein-bound iodine concentration: A study
of five contrast media, Amer. Rev. Resp. Dis., 84:386-98,
Sept. 1961.

4. Cohen, S., Perlberg, H. J., and Larde-Arthez, C. R.:
The use of Visciodol in bronchography, Radiology, 68:197-
203, Feb. 1957.

5. Distelmaier, A., Gloxhuber, C., Hecht, G., Scholtan,
W., Vieten, H., and Willman, K. H.: A new contrast me-
dium for bronchography, ‘Broncho-abrodil’ (in German),
Forschr. Roentgenstr., 95:155-65, Aug. 1961.

6. Grabiger, R.: On retention of contrast medium after
bronchography with propyliodone Cilag, Fortschr. Roent-
genstr., 93:801-03, Dec. 1960 (in German).

7. Gudbjerg, C. E. : Technique and choice of contrast
media, Acta Radiol., 42:367-73, Nov. 1954.

8. Hellstrom, B. E. : Reaction of lung on bronchography
with water soluble contrast media in rats, comparison be-
tween two media, Acta Radiol., 40:371-82, Oct. 1953.

9. Hyde, L., and Bodfish, R. E.: Effect of Propyliodone
(Dionosil) bronchograms on blood iodine and radioiodine
uptake, Dis. Chest, 39:407-11, April 1961.

10. Johnson, P. M., Benson, W. R., Sprunt, W. H., Ill,
and Dunnagan, W. A.: Toxicity of bronchographic contrast
media: an experimental investigation, Ann. Otol., 69:1102-
13, Dec. 1960.

11. Johnson, P. M., and Irwin, G. L.: An evaluation of
the pharmacological hazards resulting from use of Visciodol
in bronchography, Radiology, 72:816-28, June 1959.

12. Joyne, G. H. C., and Harnick, L. R.: Bronchography
with Dionosil, S. G. and 0., 101:425-30, Oct., 1955.

13. Koester, E., and Meyer, H. J.: Bronchography with a
new type of contrast medium (in German), Forschr. Roent-
genstr., 95:166-72, Aug. 1961.

14. Lecutier, E. R.: Approach to bronchography, Brit. J.
Tuberc., 48:184-87, July 1954.

15. Lloyd, M. S., Galler, W., and O’Connor, P. : Experi-
mental study in nebulization bronchography, Quart. Bull.
Sea View Hosp., 15:83-92, April 1954.

16. Maxwell, D. R., Reid, L., and Simon, G.: Properties
of a new contrast medium for bronchography: n-propyl
2,4,6-triiodo-3-diacetamidobenzoate (propyl docetrizoate) ,
Brit. J. Radiol., 34:744-47, Nov. 1961.

17. Mounts, R. J., and Molnar, W.: The clinical evalua-
tion of a new bronchographic contrast medium, Radiology,
78:231-33, Feb. 1962.

18. Nice, B., and Azad, M.: The use of Dionosil in bron-
chography, a preliminary report, Radiol., 66:1-8, Jan. 1956.

19. Norris, C. M., and Stauffer, H. M.: Bronchography
with Dionosil, Ann. Otol. Rhin. and Laryng., 63:520-31,
June 1954.

20. Rengarts, R. T.: Bronchography with water soluble
media, Dis. Chest, 28:558-67, Nov. 1955.

21. Salinger, P. L., and Houghton, H. G. H.: Bronchog-
raphy: a plea for the use of suspension of sulphanilamide in
iodized oil, Brit. J. Tuberc., 47:225-26, Oct. 1953.

22. Shapiro, R.: A preliminary report on the use of Ce-
sium chloride in contrast radiography, Acta radiol., 46:635-
39, Nov. 1956.

23. Smith, L. C., and Harrill, J. A.: Observations on
aqueous and oily media in lungs of experimental animals,
Ann. Otol. Rhin. and Laryng., 64:588-98, June 1955.

24. Teixeira, J., and Teixeira, L. C. : Bronchography with-
out oil and iodine: the use of barium as a contrast medium,
Dis. Chest, 36:256-64, Sept. 1959.

25. Wisoff, C. P., and Felson, B.: Bronchography with
oily Dionosil, J. Thor. Surg., 29:435-46, April 1955.

NOVEMBER 1962

297

Accreditation of Nursing Homes and
Related Facilities

CHARLES E. SCHOFF, M.D., Sacramento

It was in the all too recent past that mention of a
nursing home would conjure in the minds of most
of us a picture of a rather ponderous and ornate
structure whose designers had obviously had some
far different domestic purpose in mind when it was
built, the result being much makeshift and inconven-
ience when it was converted to its later humanitarian
purpose. Yet it was at such an establishment that
the convalescent, the chronically ill, the senile or
the debilitated aged had to be taken care of if care
could not be managed in his own home, at a rela-
tive’s or possibly a nurse’s house. Nursing care often
was a labor of love, despite physical shortcomings,
but sometimes left much to be desired. Actual expe-
rience of the patient, or observations by relatives or
physicians, provided the only means of separating
the good from the bad.

Problems in providing care for chronically ill
persons have multiplied since World War II. As a
result of changing economic forces and social hab-
its, it has become more difficult for families, fre-
quently with all adults employed, to care for the
infirm, while at the same time the pronounced
advancement in medical techniques has further
widened the disparity between the care in general
hospitals and home care facilities. So was born a
great need for more and better establishments spe-
cializing in the care of long-term illness. The result
of this was a steady increase in the number of nurs-
ing homes and related facilities — much of the in-
crease being made up of large new units that were
built for the purpose. Recent legislation providing
for partial or complete payment of nursing home
fees by government agencies has spurred the con-
struction boom.

Because of the steadily increasing scope and im-
portance of the chronic care facility, and because
considerable qualitative differences develop when
there is relatively sudden expansion in any field,
it has been apparent for some time that a measuring
method was needed so that a superior facility could
be recognized, and also so that uniform standards
could he set which could guide others in attaining a

Dr. Schoff represents the California Medical Association on the
California Commission on Accreditation of Nursing Homes and
Related Facilities.

Submitted August 3, 1962.

degree of excellence commensurate with modern
medical and nursing advancements. This measure
should augment and go beyond the requirements of
licensure, which too often concern themselves with
the appearance of the physical plant and pay little
heed to the total care of the patient.

Interested parties noted the success which had
attended the efforts of the Joint Commission on Ac-
creditation of Hospitals to provide a standard of
measure for the acute general hospital and the re-
sultant improvement in hospital care in general.
There were several attempts in various local areas
in different parts of the United States to set up
boards or groups concerned with similar improve-
ment in long-term facilities. Some of these did well
for a time, only to succumb to local or factional
differences; others remained limited in scope. Also,
there was interest on the national scale, particularly
on the part of the American Nursing Home Associa-
tion, but the very magnitude of the problem (and
its cost) made progress agonizingly slow.

In California, little was accomplished before 1959.
Then the California Joint Council to Improve the
Health Care of the Aged, which had been created to
appraise the available health resources for the aged
and foster the best possible care for this group,
recognized the important position nursing homes
and related facilities occupied in providing for
health care of old persons, many of them chron-
ically ill. The Joint Council forthwith interested
itself in the problem of improving the quality of
long-term care. Many arduous hours over a period
of nearly two years were spent by members of the
Council in formulating a set of standards for these
facilities by which comparisons could be made, spe-
cifically for the purpose of measuring, assaying and
accrediting them. As the long experience of the Joint
Commission on the Accreditation of Hospitals had
resulted in a workable guide which had been used
successfully throughout the United States for estab-
lishing and measuring hospital operation, the format
of this body was adopted as a basis for the “Stand-
ards of Accreditation” set up by the group dealing
with care of the aged. Modification was necessary,
with deletion of the non-pertinent sections and the
addition of items described jointly by the American
Medical Association and the American Nursing

298

CALIFORNIA MEDICINE

Home Association in the pamphlet Guides for Medi-
cal Care in Nursing Homes and Related Facilities,
plus certain additions made by members of the
Council itself.

After the Joint Council had completed its work
on the Standards, it was necessary to implement
them. It was for this purpose that the California
Commission for the Accreditation of Nursing Homes
and Related Facilities was created as a voluntary,
non-profit organization composed of representatives
from its supporting member organizations: the Cali-
fornia Dental Association, California Hospital Asso-
ciation, California Medical Association, California
Association of Nursing Homes, and the Southern
California State Dental Association. By providing
the Commission with a wide base composed of all
these interested parties, it was hoped, as indeed has
proved to be the case, to avoid intramural duplica-
tions, misunderstandings and the working at cross-
purposes which had resulted in the downfall of
many previous efforts. It was hoped also that placing
the program on so wide a base would at once spread
its benefits wider and avoid any purely local hin-
drances.

The first organizational meeting of the Commis-
sion was held February 21, 1961, in the meeting
room of the California Medical Association build-
ing, San Francisco. Soon afterward it set about find-
ing quarters and personnel. Money to inaugurate
the program was obtained on loan from the Crocker-
Anglo Bank, with the California Medical Association
and the California Hospital Association acting as
co-signers for four-fifths and one-fifth of the amount
respectively. Then there were manuals to be formu-
lated and surveying procedures to be worked before
the actual surveying of facilities could start. By
September 8, 1961, most problems seemed in hand
and the chairman of the Joint Commission, Pierre
Salmon. M.D., announced to interested facilities that
the accreditation program was in operation and
ready to accept applications.

It was evident that almost all facilities that ap-
plied early for accreditation were outstanding in
their level of operation and were being managed by
persons with a sense of responsibility and a feeling
of confidence that they would be certified without
difficulty. As time went on, however, there was an
increase in the number of rejections as more facili-
ties applied. As of May 31, 1962, 96 applications
had been received by the Commission. Eighty-five
facilities had been surveyed, of which 69, having
3,502 beds, had been granted full accreditation.

After the surveys had been under way for a time,
changes in procedure and some revision and altered
interpretation of the evaluation forms became neces-
sary in the light of experience. By April, 1962, the
Commission felt that it had gained sufficient knowl-

edge to undertake a complete review of its stand-
ards, the better to tailor them to evaluating the
long-term care facility. This review is still in prog-
ress. No doubt as the program continues to develop,
further reviews and modifications will be indicated.
It has also been necessary to revise some of the in-
structions to surveyors and make changes in the
surveyors’ manuals as experience has dictated.

The Commission evaluates a facility only upon
request of the management. When it receives such
a request, it first sends to the applicant information
about the standards set forth by the Commission.
Then within a reasonable time, by appointment, a
surveyor calls. His report is reviewed by the entire
Commission, which then may grant either full ac-
creditation if the facility meets all standards, or
provisional accreditation if it finds certain tempo-
rary deficiencies, or may deny accreditation if its
standards are not met. Full accreditation is for a
period of two years, provisional accreditation for
one year. The right of appeal is provided for in
cases of adverse decision.

In its survey the Commission stresses all phases
of operation, with accreditation granted to the fa-
cilities providing overall excellence. Newness of the
structure is not a governing factor. Considering the
long-term care type of patient to be dealt with, em-
phasis is placed on superior nursing, happy, conve-
nient and well-kept surroundings, programs for
rehabilitation and recreation, and proper utilization
of modern equipment and techniques. Requirements
vary according to the type of facility: establishments
registered as rest or boarding homes are not ex-
pected to offer the same services as those designated
to provide skilled nursing care and more highly
trained personnel.

Throughout the life of the Commission, it has
been stressed that it is a voluntary organization set
up to better the care of the chronically ill by help-
ing the operators of private nursing homes or re-
lated facilities to improve the quality of care and the
utilization of facilities. The Commission has no pu-
nitive function and no connection with any gov-
ernment body, but it is sometimes difficult to
convince some of the more suspicious operators
that the Commission’s surveys are solely to help the
facility attain higher standards. As the program con-
tinues to develop, its goals should become more ob-
vious. Excellence is rewarded by the certificate of
accreditation. It is the purpose of the Commission
to show others how they may improve to reach the
high standards wffiich the certificate proclaims, and
which it believes are necessary if the long-term pa-
tient is to get the kind of care of which we can be
proud.

Generally, the Commission has been satisfied with
the response to its program. As with any new en-

VOL. 97. NO. 5 • NOVEMBER 1962

299

deavor, there has been some confusion and misin-
terpretation. The institution of the Medical Aid for
the Aged Program caused certain complications,
primarily because it was not immediately made clear
what the requirements for participation in that pro-
gram would be. This problem has now been settled.

The Commission plans to be self-supporting and
to defray its expenses by making a charge for sur-
veys. At present, pending actual cost experience, it
is charging a flat fee of sixty dollars plus two and
a half dollars for each licensed bed. While the
charge may have deterred requests for surveys in
some instances, it is probable that as the worth of
the accreditation program becomes more apparent,
more facilities may be expected to feel that this ex-
pense is justified.

Much of the potential value of the accreditation
program has yet to be realized. As the superior fa-
cilities are recognized in increasing numbers, sheer
economics will require that the sub-standard facility
improve itself to survive.

Insurance covering long-term hospital care has
long been a need, but insurance carriers have never
had any means whereby they could assure them-

selves that the type of care to be provided would
justify the cost. Conformance to a set of standards
such as those set by the California Commission for
the Accreditation of Nursing Homes and Related
Facilities will assure both patient and insurance
company that the accredited facility is giving them
their money’s worth. Already, certification of the
acute general hospital by the Joint Commission on
Accreditation of Hospitals has proven to be a reli-
able aid to insurance carriers seeking to obtain supe-
rior care for their policyholders. Carriers are now
showing interest in the chronic care facility accredi-
tation program.

The Commission’s program will provide the med-
ical profession with a yardstick which it can use in
its quest for better patient care in chronic or cus-
todial care institutions. Accreditation by the Califor-
nia Commission for the Accreditation of Nursing
Homes and Related Facilities represents careful ex-
amination by a group of persons who are conversant
in the fields of medical, dental, hospital, and nursing
home care. The program is deserving of the full sup-
port of county medical societies and of individual
physicians.

1116 Twenty-Sixth Street, Sacramento 16.

300

CALIFORNIA MEDICINE

CASE REPORTS

Dental Infection Producing Severe Chronic
Headache Simulating Brain Tumor

HOWARD R. BIERMAN, M.D., and
JOSEPH TASHMA, D.D.S., Beverly Hills

The precise cause of severe headache in a given
case is often obscure and despite exhaustive studies
the eventual solution may be elusive and frustrating.
Such difficult problems are therefore of interest to
all physicians who may in the future encounter sim-
ilar conditions.

REPORT OF A CASE

A 50-year-old Caucasian housewife was first seen
in consultation on February 2, 1955, with the chief
complaint of severe right temporal headache of ten
years’ duration. She was in hospital at the time.

When the headaches first began they were se-
vere, intermittent and right-sided. Since they were
particularly severe during the winter they were at-
tributed to sinus infection. Despite repeated exami-
nations and many forms of symptomatic therapy
during the next seven years the headaches increased
in frequency and severity. At the time the patient
was seen in consultation they had been practically
continuous for three years. The typical headache
started in the right temporal region and radiated
upward, first to the vertex and then throughout the
entire upper right side of the head. The pain was
unusually sharp, lancinating and unrelenting
throughout the day and was often worse at night.
There was no pain radiation below the zygoma, to
the mouth, to the base of the skull or the neck. At
last they became so severe that they were accom-
panied by nausea and vomiting.

The patient was put in hospital for three weeks
in 1952 and a diagnosis of migraine headache was
made, presumably on an allergic basis. She im-
proved during that hospital stay, and after her dis-
charge tests were carried out for allergic sensitivity.
She was stated to be sensitive to tomatoes, pine-
apple, bananas and lobster.

However, even though she avoided these foods
religiously her headaches became progressively
more severe. Although at first they were regularly
relieved by codeine, similar analgesics and subse-
quently narcotics had progressively less effect. On
admission, the patient was taking 0.06 gm. (one

From the Institute for Cancer and Blood Research, Beverly Hills.

Submitted May 14, 1962.

grain) of codeine every three or four hours with
transient relief, and had become addicted. She had
threatened suicide as the pain became increasingly
severe and more frequent.

Thorough dental examination including roent-
genography in 1954 revealed no abnormalities.
Roentgenographic examination of the cranial si-
nuses had been carried out a few weeks before she
was admitted to hospital and the patient had been
told they were infected. The sinuses were “washed
with pressure” through the nose, the patient said,
“using penicillin.” She then received terramycin
and sulfonamides, to which she had a skin reaction,
and the medication was stopped after two days.

The patient had had a change of eye-glasses eight
months before the consultation. Hearing had re-
mained intact bilaterally. No history of trauma,
stiffness of the neck, vertigo or pertinent previous
illness could be elicited. Diagnosis upon referral
was cephalalgia, cause undetermined ; possible brain
tumor.

On physical examination no visual defects were
noted. On ophthalmoscopic examination the disc
margins were observed to be sharp; no papilledema,
vascular spasm, retinal change or other abnormality
was seen. No evidence of gingival or dental disease
was noted on examination of the month. The re-
maining teeth showed extensive restorations.

Percussion of the teeth produced no reaction; no
“trigger zones” could be identified. The heart and
lungs were found to he within normal limits. There
were two well healed incisional scars on the abdo-
men, the sites of appendectomy and hysterectomy
at the age of 29, and of nephropexy. Questioning
elicited that ice water often relieved the pain more
effectively than codeine.

Leukocytes numbered 8,800 per cu. mm. of blood,
with the cell differential within a normal range. The
hematocrit was 44 per cent; chemical components
of the blood (per 100 ml. of plasma) were: glucose,
100 mg.; non-protein nitrogen, 39 mg.; total pro-
teins, 5.6 gm., albumin 3.1 gm., globulin 2.5 gm.;
cholesterol, 159 mg.

The spinal fluid was clear and colorless, and the
initial pressure was 180 mm. (water). The protein
content was 9.8 mg. per 100 ml.; the cell count: one
mononuclear. Results of blood and spinal fluid tests
were negative for syphilis. The specific gravity of
the urine was 1.012; the pH, 6.0. There was no reac-
tion for albumin or sugar. Results of microscopic

VOL. 97. NO. 5 • NOVEMBER 1962

301

examination of the urine were: leukocytes, 1 to 3
per high-power field; epithelial cells + + +; crystals
+ ; occasional mucus threads.

X-ray films of the skull, paranasal sinuses and
chest revealed no evidence of disease. A special
x-ray examination of the teeth showed extensive
carious involvement of the pulp of the right maxil-
lary second bicuspid with inflammatory signs in
the peri-apical bone indicating some elongation of
the tooth, as well as osteolysis of the bone (Figure
1 ) . The lamina dura or bony lining of the socket
showed definite sclerosis around the peri-apical in-
fection. Additional films showed highly sclerotic
secondary dentin under the gold inlay of the second
bicuspid and the second molar, indicating a chronic
carious process.

Both the right maxillary second bicuspid and the
second molar were extracted, and the patient said
that she felt no pain during the extraction. Imme-
diately thereafter, the headaches ceased and did not
recur. The use of codeine and other analgesics was
discontinued. At last report the patient had been
free of headache for some four years.

DISCUSSION

Pain or swelling about the face or skull of unde-
termined origin is often caused by pulpal infection
of a tooth.1 Roentgenographic changes in the peri-
apical hone may not be apparent and serious intra-
cranial conditions are often considered. The extent
of peri-apical destruction of bone depends upon the
virulence, the duration and the extent of the infec-
tion.2 Repeated or continuous paroxysms of pain
with a concurrent prolonged sense of fullness may
occur in chronic hyperemia or pulpitis.

Chronic pulp infection caused by low virulent
pyogenic organisms may cause tissue changes so
slowly and gradually that recognizable symptoms
do not appear for a considerable time. During this
period the tooth generally remains vital and only
by exceedingly careful and exhaustive tests, includ-
ing heat and electric methods, can this condition be
detected. Occasionally the patient may remember
that the tooth had ached at times before being filled
or that the process of filling was attended by a great
deal of pain which might indicate deep caries and
incipient pulp involvement. Sometimes the patient
remembers the dentist was not able to remove all the
decay and “had to cap it.” In such teeth the pulp is
often diseased and necrotic. Dental pain is usually
more severe at night. Pressure during mastication is
variably painful. Foods or liquids hotter than 43°
C. may cause exacerbations of pain while cold sub-
stances often provide relief, presumably due to
vascular constriction. The origin of referred pain is
commonly obscure and may be localized in or about
the tooth or present in any part of the face supplied
by the trigeminal or tympanic nerve (Figure 2).

The present case emphasizes the absolute neces-
sity of adequate dental examination in medical prob-
lems where cranial symptoms, although not defini-
tive, are persistent. When no cause can be found by

Figure 1. — X-ray films of the right maxillary area, show-
ing peri-apical osteolysis about the second bicuspid. Note
the sclerosis of the secondary dentin under the gold inlay
of the second bicuspid and second molar.

Figure 2. — Anatomical composite drawing of the area
of pain radiation from the right maxillary second bicus-
pid and second molar.

medical examination of the usual extent, proper den-
tal consultation should be sought. If the consulta-
tion proves negative, then further and more detailed
medical studies can be initiated.

SUMMARY

A 50-year-old housewife with severe right tem-
poral headaches of ten years’ duration had a pre-
sumptive diagnosis of brain tumor. The severity of
the pain had driven the patient to codeine addiction
and suicidal thoughts.

Studies pointed to a peri-apical infection of the
right maxillary second bicuspid and molar, extrac-
tion of which was followed immediately by com-
plete and permanent relief.

Institute for Cancer and Blood Research, 9200 West Olympic
Boulevard, Beverly Hills (Bierman).

1. Gray’s Anatomy, edited by C. M. Goss, 27th Edition,
Lea and Febiger, Philadelphia, 1959.

2. Thoma, K. H.: Oral Pathology, 4th Edition, C. V.
Mosby Co., St. Louis, Mo., 1954.

302

CALIFORNIA MEDICINE

^ E D I C I N

For information on preparation of manuscript, see advertising page 2

DWIGHT L. WILBUR, M.D Editor

ROBERT F. EDWARDS . . . Assistant to the Editor

Policy Committee — Editorial Board

OMER W. WHEELER, M.D Riverside

SAMUEL R. SHERMAN, M.D San Francisco

CARL E. ANDERSON, M.D Santa Rosa

JAMES C. DOYLE, M.D Beverly Hills

MATTHEW N. HOSMER, M.D San Francisco

IVAN C. HERON, M.D San Francisco

DWIGHT L. WILBUR, M.D San Francisco

EDITORIAL

Communications

“Communications” has become almost a magic
word in business, professional and governmental
circles in recent years. It has superseded earlier
efforts at symbolizing the conveyance of informa-
tion, attitude or program from one source to an-
other.

In medical circles the term “public relations” was
long employed. This was succinctly defined as doing
or being good and then telling about it. Examples
such as the elder Rockefeller distributing shiny
dimes, or the elder Carnegie supplying funds for
the construction of libraries bearing his name, were
used as epitomizing “public relations.” In both
examples the subject was recalled as one who had
made tremendous profits at public expense and
then devoted his efforts to distributing his accumu-
lation for the public good.

Out of this procedure the subject was referred
to as “improving his public image.” This phrase
was Madison Avenue trade talk for creating a
favorable atmosphere publicly in the hope that
current goodness would counteract earlier public
condemnation.

The medical profession, once highly revered and
honored, found itself a quarter century ago placed
in a defensive position by politicians bent on im-
proving their own public images by distributing
goodies to the people. In this instance, however,
their benefits were not shiny dimes or new libraries
purchased from their own pockets but services per-
formed by physicians. The difference is noteworthy.

Placed in this defensive position, the medical
profession turned to Madison Avenue and its equiv-
alents in other cities, asking for help. From this
opening request, the word “communications” and
all that goes with it have come into being.

If we trace the history of the California Medical
Association we find that the physicians in our state
realized early in the depression days that they were
about to be gobbled up by political demands that

their services be dispensed under the control of the
state. The physicians themselves would, under such
a plan, have become pawns in the hands of the
politicians.

This was a direct political move. The answer was
to engage in counter political moves and out of this
was born the Public Health League of California.

The demand for state compulsory health insur-
ance was repeated in 1945, in 1947 and in 1949 in
California. In our national capitol, a strong move
in this direction developed in 1948. These were all
in the form of specific legislative bills. Each de-
manded crash action and each was successfully
opposed. Even so, the opposition offered was dis-
tasteful to many physicians and a demand was de-
veloped for a more subtle form of opposition under
the direct control of physicians rather than gray
flannel suited promoters.

Today the medical profession has become ac-
customed to the assumption of the care of certain
segments of the population by various government
agencies. In the state of California alone, 21 medi-
cal or health care programs are in operation by ten
agencies of state. Government, at county, state and
national levels, is in the business of providing
health care for one group or another of the people.
The aggregate encroachment on the private practice
of medicine has assumed large proportions, even
though each specific program may be miniscule by
itself.

The insurance industry is another third party
playing a prominent part in medical practice today.
The Blue plans, Shield and Cross, are another
entity.

While the profession has accepted these pro-
grams, albeit grudgingly, physicians have tended
to establish their own philosophies and standards
as to how each plan should be handled. Ask a
question on the philosophy of dealing with one
program in a group of ten physicians and you are
likely to get ten answers.

VOL. 97, NO. 5 • NOVEMBER 1962

303

Medical organizations, which carry the prestige
and authority to deal effectively with various plan
promoters, are now placed in the position of seeing
their membership divided and their own authority
curtailed in proportion to the variance in opinion.
A single question a few years back — should physi-
cians receive vendor payments from the state or
should payment be made to the patient and he be
given the responsibility of paying the doctor? —
drew vociferous opinions for patient responsibility
but an overwhelming vote for vendor payment.

These considerations bring into sharp focus the
vital need for communications. Decisions must be
made at top level and then communicated to the
membership. The members, in turn, must have
available means for expressing their wishes. When
members’ wishes can be crystallized into an estab-
lished method of procedure, the organizational
officials are in a position to act.

The California Medical Association has adopted
this concept of “communications.” In brief, the
word connotes a two-way street for the interchange
of ideas, suggestions, plans, programs. Simultane-

ously, the same avenues of information must be
kept open between officials and staff, between the
state and the component societies, between com-
mittees and officials.

With such lines of communication open, the
medical profession will be enabled to match the
old public relations formula of being or doing
good and telling about it.

The California Medical Association has now
established its informational organization in a Bu-
reau on Communications. The bureau is geared to
prompt, proper and adequate procedures in assur-
ing all interested parties of giving all others the
opportunity to learn what is going on and why.
The association has not attempted to hire outside
professional firms, counting on them to transform
the “image” of physicians into people on pedestals.
Instead, it is establishing its own internal affairs
and procedures into something alive, vibrant and
workable.

The concept is new, the opportunities vast and
the prognosis excellent.

304

CALIFORNIA MEDICINE

NOTICES & REPORTS

Council Meeting Minutes

Tentative Draft: Minutes of the 484th Meeting of
the Council, San Francisco, Hilton Inn, September
29, 1962.

The meeting was called to order by Chairman
Anderson in the Hilton Inn, San Francisco Inter-
national Airport, on Saturday, September 29, 1962,
at 10:00 a.m.

Roll Call:

Present were President Wheeler, Speaker Doyle,
Vice-Speaker Heron, Secretary Hosmer, Editor Wil-
bur and Councilors MacLaggan, Todd, O’Neill,
Bullock, O’Connor, Ham, Rogers, Cosentino, Gruni-
gen, Dalton, Murray, Davis, Miller, Watts, Campbell,
Morrison, Kaiser, Anderson and Dozier.

Absent for cause, President-Elect Sherman, Coun-
cilors Wilson and Quinn.

A quorum present and acting.

Present by invitation were Messrs. Hunton,
Thomas, Clancy, Marvin, Whelan, Clark, Klutch,
Edwards and Bowman, Doctor Miller and Mrs.
Griffith of C.M.A. staff; Messrs. Hassard and Huber
of legal counsel; Eugene Salisbury of the Public
Health League; county executives Lingerfelt of
Fresno, Geisert of Kern, Baker of Los Angeles,
Brayer of Riverside, Donmyer of San Bernardino,
Nute of San Diego, Neick of San Francisco, Thomp-
son of San Joaquin, Wood of San Mateo, Grove of
Monterey and Rosenthal of Forty First; Messrs.
Heller, Nyron and Paolini and Doctor T. Eric
Reynolds of California Physicians’ Service; Messrs.
John Pompelli and Dick Philleo of the Ameri-
can Medical Association; Dean Mellinkoff and
Associate Dean Field of University of California,
Los Angeles, School of Medicine; Doctor Malcolm
Merrill, director of the State Department of Public
Health; Doctor Daniel Blain, State Director of Men-
tal Hygiene; Mrs. Eunice Evans of the State De-
partment of Social Welfare; Doctor Donald Abbott
of the State Board of Medical Examiners; Doctor
Joseph Shebl, president of the Monterey County
Medical Society; Doctor Gerald W. Shaw, and others.

1. Minutes for Approval:

On motion duly made and seconded, minutes of
the 483rd Council meeting, held August 25, 1962,
were approved.

2. Membership:

(a) A report of membership as of September 26,
1962, was presented and ordered filed.

(b) On motion duly made and seconded in each
instance, 12 applicants were voted Associate Mem-
bership. These were: Philip Geller, Arthur Gropper,
John P. Meehan, Jr., Paul F. Wehrle, Los Angeles
County; William Clover, Ethel A. Chapman, Salva-
dor A. Macis, San Bernardino County; Gilbert M.
Clarke, Robert R. Eggen, Robert N. Hamburger,
James W. Turpin, San Diego County; Carl T. Du-
puy, San Luis Obispo County.

(d) On motion duly made and seconded, 11
members were granted reductions of dues because
of illness or postgraduate study.

(e) On motion duly made and seconded, Doctor
Emmett L. Tisinger of San Bernardino County was
voted reinstatement of his membership for 1960
and 1961 in order to clarify his membership records.

OMER W. WHEELER, M.D President

SAMUEL R. SHERMAN, M.D President-Elect

JAMES C. DOYLE, M.D Speaker

IVAN C. HERON, M.D Vice-Speaker

CARL E. ANDERSON, M.D. . . Chairman of the Council

BURTL. DAVIS, M.D. . . . Vice-Chairman of the Council

MATTHEW N. HOSMER, M.D Secretary

DWIGHT L. WILBUR, M.D Editor

HOWARD HASSARD Executive Director

JOHN HUNTON Executive Secretary

General Office, 693 Sutter Street, San Francisco 2 • PRospect 6-9400
ED CLANCY Director of Public Relations

Southern California Office:

1515 N. Vermont Avenue, Los Angeles 27 • 663-8071

VOL. 97, NO. 5 • NOVEMBER 1962

305

3. State Fee Schedules:

Discussion was held on the progress of conferences
with representatives of the State Department of
Finance on the level of medical fees allowed by
various departments administering medical care
programs.

Councilor Bullock offered the following motion :
Resolved: That we recommend to the State that
all physicians be allowed to charge their usual
and normal fee for services to this group and
that in case funds available for this year be
exhausted, that we will recommend to all of
our members that their patients be treated with-
out charge for the remainder of the year.

The motion was lost for want of a second.

On motion duly made and seconded, it was voted
to authorize the Committee for Emergency Action,
in discussions with the State Department of Finance,
to (1) reaffirm that the C.M.A. cannot hind any
physician to participation in state financed medical
care programs, and (2) state that any schedule of
fees should he based upon a Relative Value factor
that would represent a level acceptable to the ma-
jority of the state’s physicians.

4. Report of the President:

President Wheeler reported on the fall board
meeting of the Woman’s Auxiliary. Fie also reported
that the Santa Barbara County plan to handle wel-
fare medical care programs through underwriting
by California Physicians’ Service had been approved
and would go into effect in a few weeks.

Doctor Wheeler also called attention to a Congress
on Mental Health scheduled by the American Medi-
cal Association, at which representatives of the
C.M.A. would be present.

5. Finance Committee:

(a) Chairman Davis of the Finance Committee
reported the recommendation of the committee that
county society public relations programs, which
seek C.M.A. financial support, should be considered
on their individual merit and should first be pre-
sented to the Bureau on Communications and, if
bureau approval is achieved, be presented to the
council and thence to the Finance Committee. This
recommendation was approved.

(b) The committee recommended that an ad hoc
committee to study Mr. James Bryan’s communica-
tions study should be considered a Council com-
mittee and not be given a budget appropriation.

(c) The committee recommended and the Coun-
cil approved, on motion duly made and seconded,
that all Alternate Delegates to the A.M.A. should

attend the Los Angeles session of the A.M.A. and be
allowed per diem expenses.

(d) The committee recommended that alloca-
tions of $500 for a committee on the medical aspects
of sports, $2,500 for ad hoc committee #1 of the
House of Delegates, and $1,200 for ad hoc com-
mittee §2 of the House of Delegates be provided to
cover committee costs. On motion duly made and
seconded, these appropriations were approved.

(e) The committee recommended that the budget
be studied and approved by the Council sufficiently
early to permit it to be mailed out in condensed form
to all delegates and alternates one month before the
annual meeting and that the finance reference com-
mittee be appointed at an early time so that those
delegates having comments or inquiries about the
proposed budget could relay these to the reference
committee in advance of the annual session.

ff) The committee recommended and the Coun-
cil, on motion duly made and seconded, approved
a plan to provide for deferred compensation for the
Executive Director, details of which will be approved
by the Finance Committee.

6. Medical Schools :

(a) Dean Mellinkoff of U.C.L.A. School of Med-
icine and Associate Dean Field were introduced to
the Council and reported their wish to continue
liaison with the Association.

(b) Councilor Watts, Associate Dean of the Uni-
versity of California School of Medicine, San Fran-
cisco, requested the support of the Association for
Proposition 1-A on the November ballot. This
proposal has been referred to the Committee on
Legislation.

7. State Department of Public Health:

Doctor Malcolm Merrill, State Director of Public
Health, reported that allocations of state and federal
funds for hospital construction had been approved
for a $45 million building program and that reports
of the northern and southern hospital planning
committees are close to completion.

Doctor Merrill also gave progress reports on
studies into glue-sniffing by minors, use of chemicals
in foods and polio immunization programs. He also
reported a regulation adopted to prohibit the sale
or transportation of pet skunks because of the rabies
hazard. He also reported that the Hoxsie treatment
for cancer had been declared a misdemeanor.

8. State Department of Mental Hygiene:

Doctor Daniel Blain, state Director of Mental
Hygiene, reported that his department believes that
research is the answer to irreversible cases of
brain damage and that the department is concerned
over the curtailment of drugs used in treating men-
tal cases. Doctor Blain also reported that prog-

306

CALIFORNIA MEDICINE

ress is being made in the coverage of mental condi-
tions by health insurance and that enlargement in
this field will permit more patients to receive treat-
ment under private auspices.

Doctor Blain also reported that within a special
Committee on Insanity, which includes physicians,
there has developed a sharp difference of opinion
between himself and another physician and that this
difference may soon emerge before the public.

9. State Department of Social Welfare:

Mrs. Eunice Evans of the State Department of
Social Welfare reported that the department was
looking forward to the Santa Barbara County pro-
gram of underwriting welfare medical care programs
through California Physicians’ Service as a valuable
pilot program.

Mrs. Evans also reported that legislation adopted
by the Congress had permitted the provision of care
for some mental patients, a group previously not
eligible for such care.

10. State Board of Medical Examiners:

Doctor Donald Abbott, member of the State
Board of Medical Examiners, reviewed the history
of medical licensure in California and assured the
Council of the board’s desire to maintain liaison
with the C.M.A.

11. California Physicians' Service:

Doctor John Morrison reported that C.P.S. has
developed its new MD-65 program and, in southern
areas, will provide the complete service because of
inability to reach an agreement with Blue Cross.
The program is being widely advertised at this time.

Doctor Morrison read to the Council a letter
which C.P.S. proposed to send to all Congressional
candidates, outlining this program and indicating
the availability of medical care to older citizens.
On motion duly made and seconded, this mailing
was approved.

Doctor Morrison also reported the death of Mr.
Martin Webb, C.P.S. controller, and suggested that
the Council adjourn the meeting in his memory.

12. Delegation to American Medical Association:

Doctor Wilbur, chairman of the A.M.A. delega-
tion, suggested that the Delegates to the A.M.A. be
invited to meet with the Council at its next meeting,
in order to discuss items which might be presented
to the A.M.A. House of Delegates in November.
On motion duly made and seconded, it was voted
to extend this invitation.

13. Ad Hoc Committee on Scientific Board:

Doctor Wilbur presented a list of some medical
specialty organizations proposed for recognition for

appointment of members of the Scientific Board.
On motion duly made and seconded, this list was
approved, subject to further additions. This list
reads :

1. California Society of Anesthesiologists, Inc.

2. California Academy of General Practice

3. American College of Surgeons

a. Northern California Chapter

b. Southern California Chapter

4. American College of Obstetricians & Gynecologists, Cali-

fornia Chapter

5. Western Orthopedic Association

a. Northern California Chapter (Fresno North)

b. Los Angeles Chapter (below Fresno-Newport Beach)

c. San Diego Chapter (below Newport Beach to border)

6. California Society of Pathology

7. American Academy of Pediatrics (State of California

Chapter)

8. a. Northern California Society of Physical Medicine &

Rehabilitation

b. Southern California Society of Physical Medicine &
Rehabilitation

9. American Psychiatric Association

a. Northern California Chapter

b. Central California Chapter

c. Southern California Chapter

10. The California Radiological Society

11. American College of Physicians

a. Northern California Region

b. Southern California Region

12. International College of Surgeons

a. Northern California Chapter

b. Southern California Chapter

13. California Academy of Preventive Medicine

14. American Urological Association, Western Section

14. Bureau on Communications :

On motion duly made and seconded, recommen-
dation 33 in Mr. James Bryan’s survey of com-
munications, relative to employment of a director
of communications, was voted approval.

15. Proposition 22:

Mr. Bob Garrick, campaign manager for the Com-
mittee on Medical Progress, working for an affirma-
tive vote on Proposition 22, gave a progress report,
announced that campaign material had been sent to
all members and urged complete cooperation in
behalf of this measure to complete the unification
of the medical and osteopathic professions in Cali-
fornia.

16. Bureau of Research & Planning:

Doctor Gerald Shaw, chairman of the Bureau of
Research & Planning, gave a progress report on
several studies now under way. He also reported that
a report on medical care programs for elder citizens
has been completed and that figures on premium
costs are being compiled. On motion duly made and
seconded, it was voted to approve distribution of
this report when adequate premium data are avail-
able.

VOL. 97, NO. 5 • NOVEMBER 1962

307

17. Commission on Medical Services:

Doctor John F. Murray reported that the Com-
mittee on Government Financed Medical Care was
planning to seek the use of the 1960 Relative Value
Studies in the Medicare program for military de-
pendents. The committee is concerned, he reported,
with its position relative to fees and its relationship
with California Physicians’ Service and its fee
committee.

18. Commission on Public Agencies:

Doctor James C. MacLaggan, chairman of the
Commission on Public Agencies, gave a progress
report on the polio immunization programs staged in
various areas of the state.

19. Committee on Scientific Work:

Doctor Albert C. Daniels, chairman of the Com-
mittee on Scientific Work, reported on plans made
by the committee for the scientific program at the
1963 Annual Session. He also presented the recom-
mendation of the committee that the Association
refuse to accept technical exhibits by tobacco com-
panies. It was pointed out that this prohibition would
extend also to journal advertising. On motion duly
made and seconded, it was voted to accept the
committee’s report with the exception of the recom-
mendation on tobacco exhibits.

20. Committee on Committees:

(a) Doctor Wheeler recommended that Doctor
Joseph P. Cosentino be appointed a member of the
Committee on Committees. On motion duly made
and seconded, this appointment was approved.

(b) Doctor Wheeler also recommended that a
committee be appointed to review accreditation pro-

cedures for members of the Forty First Medical
Society who have not had their specialty training
recognized by the American Boards. On motion
duly made and seconded, it was voted to appoint
such a committee, with Doctor Wilbur to serve as
the Council’s representative and with consultants to
be called as needed.

21. Commission on Cancer: .

Doctor Davis reported that the Commission’s re-
port on patient needs was being rewritten and would
be presented at a later date.

22. Association Mailing List:

A request for use of the C.M.A. mailing list by a
group of private colleges and universities was pre-
sented and a motion made to endorse the proposition
but decline the use of the mailing list. On vote, this
motion was lost.

Motion was made and seconded to grant the use
of the mailing list for this purpose and, on vote, was
lost. Doctor Bullock asked to be recorded as voting
in favor of this motion.

23. Time and Place of Next Meeting:

The chairman announced that the next meeting
of the Council would be held in Los Angeles on
November 3, 1962.

Adjournment:

There being no further business to come before it,
the meeting was adjourned at 4:15 p.m. in the
memory of Martin Webb.

Carl E. Anderson, M.D., Chairman
Matthew N. Hosmer, M.D., Secretary

308

CALIFORNIA MEDICINE

Symposium on the
Adrenal Cortex

1963

Symposium on the Pancreas

Annual Session

Panel on Diabetes

CALIFORNIA MEDICAL ASSOCIATION

Problems of Gonadal Function

March 23 to 27

Spotlight on Medicine

AMBASSADOR HOTEL • LOS ANGELES

Twenty-One Specialty Group
Meetings

GENERAL THEME:

Basic Science Session

Endocrinology and Inborn
Errors of Metabolism

Fourteen Medical Motion
Picture Symposia

5 OUTSTANDING GUEST SPEAKERS:

Presidents’’ Dinner Dance —
Sunday, March 24 —
Cocoanut Grove

STEFAN S. FAJANS, M.D., Professor of Internal
Medicine, Division of Endocrinology and Metabo-
lism, University of Michigan Medical Center, Ann
Arbor.

MELVIN M. GRUMBACH, M.D., Associate Professor
of Pediatrics, College of Physicians and Surgeons
of Columbia University, New York.

House of Delegates —

Opening Session,

Saturday, 7 :00 p.m., March 23;
T uesday Afternoon, March 26,
and Wednesday, March 27

GEORGE J. HAMWI, M.D., Professor of Medicine-
Endocrinology, Director of Clinical Research Unit,
Ohio State University Hospital, Columbus; and
President of the Ohio State Medical Association.

Cancer Conferences on
Pathology and Radiology —
Saturday, March 23

JAMES D. HARDY, M.D., Professor and Chairman
of the Department of Surgery; and Director of
Surgical Research, Surgeon-in-Chief to the Uni-
versity Hospital, University of Mississippi Medical
Center, Jackson.

Registration Daily —
No Registration Fee

CHARLES W. LLOYD, M.D., Senior Scientist; Direc-
tor of the Training Program of Reproductive

HOTEL RESERVATIONS— MAKE

Physiology and Director of the Endocrine Research
Clinic, Worcester Foundation for Experimental

ALL HOTEL RESERVATIONS THROUGH
C.M.A. HOUSING BUREAU—

Biology, Shrewsbury, Massachusetts.

SEE PAGE 311.

3n jfflemo riant

Bogen, Emil, Arcadia. Died September 19, 1962, in Bur-
bank, aged 66, of heart disease. Graduate of the University
of Cincinnati College of Medicine, 1923. Licensed in Cali-
fornia in 1923. Doctor Bogen was a member of the Los An-
geles County Medical Association.

Goorwitch, Joseph, Los Angeles. Died October 1, 1962,
in Los Angeles, aged 57. Graduate of Rush Medical College,
Chicago, Illinois, 1935. Licensed in California in 1936. Doc-
tor Goorwitch was a member of the Los Angeles County
Medical Association.

Hillyer, LeRoy, Los Banos. Died October 3, 1962, in
Los Banos, aged 66, of heart disease. Graduate of the Uni-
versity of Texas Branch of Medicine, Galveston, 1922. Li-
censed in California in 1928. Doctor Hillyer was a member
of the Merced County Medical Society.

❖

Jamentz, Samuel K., Pasadena. Died September 15,
1962, in Pasadena, aged 87, of metastatic adenocarcinoma
to the liver, probably adenocarcinoma of sigmoid. Graduate
of the University of Michigan Medical School, Ann Arbor,
1904. Licensed in California in 1921. Doctor Jamentz was
a retired member of the Los Angeles County Medical Asso-
ciation and the California Medical Association, and an asso-
ciate member of the American Medical Association.

Johnson, Harold Stephen, Long Beach. Died September
22, 1962, in Long Beach, aged 64, of gastro-intestinal hem-
orrhage. Graduate of the College of Medical Evangelists,
Loma Linda-Los Angeles, 1925. Licensed in California in
1926. Doctor Johnson was a member of the Los Angeles
County Medical Association.

Kern, Louis R., Los Angeles. Died October 5, 1962, in
Los Angeles, aged 47. Graduate of the College of Medical
Evangelists, Loma Linda-Los Angeles, 1945. Licensed in
California in 1946. Doctor Kern was a member of the Los
Angeles County Medical Association.

Kuh, Clifford, Oakland. Died September 15, 1962, in
Oakland, aged 69. Graduate of Yale University School of
Medicine, New Haven, Connecticut, 1932. Licensed in Cali-
fornia in 1942. Doctor Kuh was a retired member of the
Alameda-Contra Costa Medical Association and the Cali-
fornia Medical Association, and an associate member of the
American Medical Association.

Morgan, John A., Modesto. Died September 30, 1962, in
Modesto, aged 45. Graduate of the University of California
School of Medicine, Berkeley-San Francisco, 1942. Licensed
in California in 1942. Doctor Morgan was a member of the
Stanislaus County Medical Society.

Morris, John Knox, Jr., Modesto. Died September 16,
1962, in Modesto, aged 65, of heart disease. Graduate of
Stanford University School of Medicine, Palo Alto-San Fran-
cisco, 1924. Licensed in California in 1924. Doctor Morris
was a member of the Stanislaus County Medical Society.

Pyle, Wynand, Pasadena. Died October 2, 1962, in Pasa-
dena, aged 74, of coronary occlusion. Graduate of Wayne
University College of Medicine, Detroit, Michigan, 1915.
Licensed in California in 1943. Doctor Pyle was a member
of the Los Angeles County Medical Association.

Ress, Irvinc Leroy, Beverly Hills. Died September 16,
1962, in Los Angeles, aged 58, of coronary occlusion. Gradu-
ate of Northwestern University Medical School, Chicago,
Illinois, 1930. Licensed in California in 1931. Doctor Ress
was a member of the Los Angeles County Medical Associa-
tion.

Thom, Wenonah King, Chico. Died September 27, 1962,
aged 56, from multiple injuries received in an automobile
crash. Graduate of the University of California School of
Medicine, Berkeley-San Francisco, 1930. Licensed in Cali-
fornia in 1930. Doctor Thom was a member of the Butte-
Glenn Medical Society.

Townsend, Guy Walter, Los Angeles. Died September
26, 1962, in Los Angeles, aged 73. Graduate of Creighton
University School of Medicine, Omaha, 1910. Licensed in
California in 1923. Doctor Townsend was a retired member
of the Los Angeles County Medical Association and the
California Medical Association, and an associate member
of the American Medical Association.

Turley, John G., Los Angeles. Died September 13, 1962,
in Sawtell Veterans Hospital, aged 88. Graduate of Barnes
Medical College, St. Louis, Missouri, 1899. Licensed in Cali-
fornia in 1923. Doctor Turley was a retired member of the
Los Angeles County Medical Association and the California
Medical Association, and an associate member of the Amer-
ican Medical Association.

Wynns, Harlin LeRoy, San Carlos. Died September 12,
1962, in San Carlos, aged 61. Graduate of University of
California School of Medicine, Berkeley-San Francisco,
1929. Licensed in California in 1929. Doctor Wynns was a
member of the San Mateo County Medical Society.

Zumwalt, Fred H., San Francisco. Died September 16,
1962, in San Francisco, aged 82. Graduate of the University
of California School of Medicine, Berkeley-San Francisco,
1902. Licensed in California in 1902. Doctor Zumwalt was a
retired member of the San Francisco Medical Society and
the California Medical Association, and an associate mem-
ber of the American Medical Association.

310

CALIFORNIA MEDICINE

APPLICATION
FOR HOTEL
ACCOMMODATIONS

9>d Annual
Session

CALIFORNIA MEDICAL
ASSOCIATION

March 23* to 27, 1963
LOS ANGELES

*House of Delegates Opening Ses-
sion Saturday evening, March 23;
Scientific Programs begin Sunday
morning, March 24.

INFORMATION

1. Please fill in the form below completely for room accom-
modations at the CMA's 1963 Annual Session. There is only
a limited number of single rooms available. Your choice of
accommodations will be better if your request is for rooms
to be occupied by two or more persons.

2. Your reservation request should include the definite date
and hour of your arrival and departure.

3. Reservations can only be held until 6:00 p.m.

4. All reservations must be made through the CMA
Housing Bureau, Dept. 34, 693 Sutter Street, San
Francisco 2, California.

5. DEADLINE for Housing — March 1, 1963.

HOTEL ROOM RATES*

Single Twin Suites

AMBASSADOR HOTEL

3400 Wilshire Boulevard

Main Building $14.00-$24.00 $1 8.00-$28.00 $40.00-$58.00

Garden Suites .. $22.00-$34.00 $24.00-$36.00 $54.00-$66.00

CHAPMAN PARK HOTEL

3405 Wilshire Boulevard

Main Building $1 0.00-$1 1 .00 $1 5.00-$1 8.00 $20.00-$28.00

Bungalows (suites) $28.00-$48.00

THE GAYLORD HOTEL

3355 Wilshire Boulevard $1 0.00-$1 2.00 $1 2.00-$l 5.00 $25.00-$35.00

HOTEL CHANCELLOR

3191 West Seventh Street $10.00 $12.00-$14.00 none

SHERATON-WEST

2961 Wilshire Boulevard $1 3.00-$20.00 $1 8.00-$25.00 $34.00

tThe above quoted rates are subject to change.

CALIFORNIA MEDICAL ASSOCIATION — Housing Bureau, Dept. 34

693 Sutter Street

San Francisco 2, California

Please reserve the following accommodations for the 92nd Annual Session of the California Medical Association, in Los
Angeles, March 23-27, 1963. First meeting of the House of Delegates begins Saturday evening, March 23; Scientific Programs
begin March 24.

Single Room $ Twin-Bedded Room $

Small Suite $ Large Suite $ Other Type of Room $

First Choice Hotel Second Choice Hotel

ARRIVING AT HOTEL (Date): Hour: A.M P.M. [ Hotel reservations will be held until

Leaving (date) Hour: A.M. P.M. 6:00 p.m., unless otherwise notified.

THE NAME OF EACH HOTEL GUEST MUST BE LISTED. Therefore, please include the names and addresses of both persons
for each twin-bedded room requested; and names and addresses of all other persons for whom you are requesting reservations
and who will occupy the rooms asked for:

Individual Requesting Reservations — Please print or type:

Name

Address

Are you a CMA Officer? .A Delegate? An Alternate?

County

City and State

VOL. 97, NO. 5

NOVEMBER 1962

311

No. 13*

'‘Second Aid”

Many PHYSICIANS consider rehabilitation a procedure to be done after most
active treatment is completed. Although this is more or less true with regard
to some modalities of physical and vocational rehabilitation, there is another
aspect of the problem that should be emphasized.

Rapport and confidence between patient and physician are definite
factors involved in recovery from injury or disease. A suddenly disabled
workingman encounters many social and psychological problems along with
his physical difficulties. If these are not resolved along with the treatment
of the physical needs, maximum recovery may be delayed or complicated.
With a little added effort, most of these situations can be controlled or relieved
by the treating physician.

The most apparent social problems facing the disabled worker involve
partial loss of income, concern over how much time he will lose from work,
over his ultimate ability to return to usual employment and over job security.
An early explanation to the patient of the nature of the condition, a realistic
estimate of the length of disability and a conservative but encouraging prog-
nosis regarding his final physical status will be of great assistance. A general
description of the treatment procedures and evidence of a sincere interest in
the patient’s maximum recovery will reduce confusion and anxiety.

“Second Aid” of this kind should be started soon after the beginning of
treatment. If the patient exhibits apprehension regarding progress or modali-
ties of treatment, a prompt consultation may often obviate anxiety. If partial
or total permanent disability that would prevent return to usual employment
is foreseen, the physician should accept the responsibility for helping the
patient to seek vocational guidance and rehabilitation as early as possible.
If this is delayed, the patient’s motivation is frequently lost. In some instances,
an early return to modified duty is the best form of rehabilitation.

Committee on Occupational Health
California Medical Association

Comments and Questions Are Welcomed by the Committee

*This is the thirteenth of a series of articles prepared by the Committee on Occupational Health.

312

CALIFORNIA MEDICINE

PUBLIC HEALTH REPORT

MALCOLM H. MERRILL, M.D., M.P.H.
Direcfor, State Department of Public Health

California is taking the lead in making direct use
of water reclaimed from sewage, and developments
are being closely observed throughout the nation.

Use of sewage effluent for irrigation of fodder
crops has long been employed in the interior farm-
ing communities of California, and since 1947 San
Francisco’s famed Golden Gate Park has been ir-
rigated with effluent.

In addition, seven golf courses in southern Cali-
fornia use disinfected sewage effluent for spray
irrigation, and similar plans are under study for
Griffith Park in Los Angeles, and Balboa Park in
San Diego.

The most dramatic of the current reclamation
operations is that of the Santee County Water Dis-
trict in San Diego County. Sewage effluent which
has received the normal elements of complete water
treatment is percolated into the sands and gravels
of a natural canyon, recaptured after a half mile
of underground flow and formed into a chain of
recreational lakes. These lakes, located at the en-
trance of a new community of some 20,000 people,
form the center of an attractively landscaped recrea-
tional area for boating and fishing.

The criteria of success of these methods are:
public health safety, acceptable chemical quality and
hydraulic feasibility.

1 i i

On September 1, California assumed regulatory
authority over most radioactive materials in the
state. This was the culmination of a long series of
legislative and administrative steps which began
with 1959 Congressional action that permitted
transfer of regulatory authority from the Atomic
Energy Commission to the states.

Some 1,000 organizations will be required to
obtain radioactive material licenses from the State
Health Department, and will be subject to inspec-
tion by state or local experts.

Radioactive materials have many beneficial uses
in industry, medicine, research and education. The
legislatively declared policy of California is to
encourage such uses, while assuring that health and
safety are not jeopardized.

i i 1

The Bureau of Maternal and Child Health is ex-
ploring the feasibility of incorporating auditory
screening of infants as a routine part of child
health conferences.

Studies have indicated that recently developed
auditory screening procedures for infants can be

included in routine child health supervision at well
child conferences and in the pediatrician’s office.
While such procedures are not designed to measure
hearing acuity, they do serve to identify infants who
fail to respond to selected auditory stimuli in a
manner consistent with normal growth and develop-
ment patterns.

Failure of a child to pass such screening tests
may indicate the need for further otologic, audio-
logic, neurologic and psychological evaluations, thus
permitting the application of appropriate therapy
at an early age to obviate the development of more
serious communicative disorders.

The U. S. Public Health Service maintains the
national hospital for leprosy at Carville, La. This
hospital is open to all patients with confirmed
leprosy; no person with a confirmed case may be
rejected, nor can a patient be held there against his
will or denied readmission after once being
admitted.

The present population of the hospital is over 300
patients, but only 67 of these are so acutely ill
as to require infirmary care. The remainder are
housed in dormitories, single apartments or apart-
ments for married couples. All maintenance costs
are assumed by the hospital. Many patients are pro-
vided with part-time employment in the hospital
and some carry on private enterprises on the
premises.

Treatment of acute cases involves use of the
sulfone drugs, streptomycin, isoniazid and steroids.
Chemotherapy results in severe systemic reactions
in approximately 20 per cent of the cases treated.

An extensive program of rehabilitation is carried
on using physical therapy, occupational therapy, ap-
propriate prosthesis, along with continuous patient
evaluation. Efforts are being made to restore more
and more suitable patients to their homes by ar-
ranging occupational and social placement through
liaison units and local social welfare departments.

However, many patients prefer to remain at Car-
ville, not for medical indications but because of
social and emotional inability to adjust to life in
the home area. The present philosophy in handling
cases is greatly hampered by lack of facilities for
individual surveillance in many local areas. To date,
California and Hawaii are the only states which pro-
vide for medical supervision of leprosy cases in
their home communities.

VOL. 97, NO. 5 • NOVEMBER 1962

313

The Auxiliary and Politics

The scope of auxiliary programs covers many
aspects of community service. If asked why we are
concerned with such diverse projects, our answer
would be: Assurance to the public that we are vitally
interested in good government. We eagerly donate
time and effort to causes that are related to the
betterment of our community. Our interests are all
keyed to helping others to help themselves. While
in particular we are striving to keep medicine a
free, unencumbered profession, that aim is a part
of our wish to fulfill our moral obligation to those
around us.

Medicine has been singled out as one of the first
targets for socialization. It is incongruous that
medicine should be selected, for no other profession
can boast a comparable record of contribution to
humanity. Its insistence that the health of the nation
is paramount, may be one of the keys to its present
problems. Because physicians always had an unsel-
fish devotion to the welfare of their patients, they
are reluctant to believe that government bureaucracy
would question their ability to render the best medi-
cal care in the world. The events of the past few
years, how'ever, have brought them to a full realiza-
tion of what some government officials have in mind
for them. This has only served to unite them in a
common effort to meet this threat. We in the
Woman’s Auxiliary are joining our forces with our
husbands’ to prove that we are not protecting selfish
interests.

Since proponents of these government programs
are trying to place medicine under their control, we
have been forced into the political arena. It is not
only from a medical standpoint that we oppose such
government interference, but because it is a threat
to all private enterprise. We are staunch supporters
of constitutionalism and the rights of the individual.

We have just been through a crucial national
election. Our government legislators have been
selected and will be taking office in January. Are
you happy with the results? Are your representa-

tives imbued with a philosophy of constitutional
government? Do they have a true sense of fiscal
responsibility? Do they believe in our way of life
based on individual freedom and free enterprise?
If the answer to any of these questions is no, it
could be our apathy and complacency that put such
persons in office. Maybe our refusal to forget party
lines helped in the election of men who are the
antithesis of everything we expect from government.
In retrospect, did we really respond wholeheartedly
when called on to do pre-election campaigning?
Maybe one more phone call, an extra hour spent in
precinct work or a few hours spent on election day
taking friends to the polls might have assured us
that we would not be faced with Forand-type legis-
lation in 1963.

Now that the decisions have been made, we must
anticipate and prepare for the next two years. The
administration has promised the reintroduction of
a new medicare bill. It will probably be a revision
of the King-Anderson bill, with concessions made
on some points to help its passage, but maintaining
the Social Security approach. We all have vast sup-
plies of material for combating this legislation,
although some of it may vary in minor details with
any new bills presented in January. The next two
months can be used profitably in continued educa-
tion against any form of government medicine. We
are sponsors of good medicine, regulated by per-
sons best qualified — physicians. We disagree with
those who would burden our future generations
with an insurmountable tax load, to take care of us
in later years, whether we need such help or not.

Most newly elected officials will remain in their
respective districts for the next two months. If you
have not already done so, it is urgent that you get
acquainted with them. In some instances, they will
be new to the field of politics, in others incumbent.
They may not all agree with your point of view,
but that should not preclude making your ideas
known to them. They are responsible to you, their
constituents, and they are politically alert enough
to know they must consider your opinion when they

314

CALIFORNIA MEDICINE

Medical Association, we have the added advantage
of membership in the largest state auxiliary. This
carries with it increased responsibilities. We should
lead in action. The other states will be looking to
us to set a precedent. Living up to this position
will require the co-operation of each of our 7,000
members. If we do nothing more than fulfill our
commitments to the California Medical Association,
with the advice and assistance they have given us,
we will be first in legislative matters.

Mrs. Robert J. Douds, Chairman
Committee on Legislation
Woman s Auxiliary to the C.M.A.

are making their decisions. Let them know you are
watching their voting record. Correspond with them
frequently when they are away from home. Com-
mend them when they take a stand supporting our
ideals. Do not always ask for favors. Senator Byrd,
Chairman of the Senate Finance Committee, has
said, “The average citizen has power he seldom
realizes. For one thing he has the power of the
pen.”

As women, we are members of the largest voting
majority. We can sway public opinion and influence
votes if we make full use of our potential. Being
members of the Woman’s Auxiliary to the California

VOL. 97, NO. 5 • NOVEMBER 1962

315

LETTERS to the Editor

Each member of the California Medical Associa-
tion recently received a copy of the amended Official
Minimum Medical Fee Schedule of the Industrial
Accident Commission.

It should be called to the attention of the member-
ship that this is, as stated in its title, a schedule of
minimum fees. It does not preclude usual and cus-
tomary charges by physicians, providing the insur-
ance carrier is willing to pay normal fees for the
medical services provided.

Edgar Rosen, M.D.
447 - 29th St.,

Oakland 9

Cancer Therapy — Evaluation of
Supervoltage X-Ray

Doctor Lewis Jacobs’ article, “Cancer Therapy —
Evaluation of Supervoltage X-ray: A Review of the
Literature” in the September 1962 issue of Califor-
nia Medicine, contains some statistical errors whose
correction changes the implications of his review.

The article in question lists the results of a num-
ber of published studies of five-year survivorship
under radiation therapy, plus the voltage used in
each study, and tests the equality of the survival
rates by chi-square. This is done separately for
cancer of the tonsil and for cancer of the ovary, as
examples of relatively accessible and relatively in-
accessible sites. No significant variability in survival
rates is found for either site.

The formula used for chi-square is in error. It
should he multiplied by one less than the number
of studies (16 for tonsil, 11 for ovary). This, plus
the correction of minor arithmetic errors, leads to
chi-squares of 69.97 (so significant that it isn’t
tabled) for tonsil and 24.75 (significant at the 1
per cent level) for ovary. This result is much less
surprising than the published one, in view of the
probable differences from study to study in age of
patients, stage of cancer, selection criteria for radi-
ation versus surgery, etc.

Having found such spectacular variations, and
having some idea of the manifold uncontrolled
factors which may be invoved, it is clear that further
examination of the data can lead us at best to con-
jectures, which must ultimately be confirmed by
more carefully controlled investigations.

The further examination should logically consist
in deciding whether the observed variation is asso-
ciated to any significant extent with variation in
voltage. This can be done by calculating separate
chi-squares for the variation (a) within the high
voltage group, (b) within the other group (ortho-
voltage-not stated) and (c) between the high volt-
age and the other group. Since these represent all
possible sources of variation, these chi squares add
up to the overall chi square calculated above, except
for round-off error. The results of these calculations
are shown in the table.

Source of Variation

Tonsil

Ovary

Significance

Within high voltage...

.. 5.27

1.14

Within other

. 64.59

<1%

21.88

<1%

Between groups

. .03

1.46

69.97

<1%

24.75

<1%

For both sites, the significant variation occurs
within the “other” group, not within the high voltage
group or between the two groups. In other words,
any significant difference which may exist between
the high voltage group and the “other” group for
either site is swamped by the extreme variability of
the other group. Therefore the failure to find such
a difference in these data is not a very strong reason
to conclude that none exists. I think the verdict
should be “not proved.”

Sincerely,

William R. Gaffey, Ph.D.

Statistical Consultant, Divison of Research,
State of California Department of Public
Health

* * *

Dr. Jacobs' Reply

Thank you for letting me see Dr. Gaffey’s criticism.
I think that his last paragraph really agrees in all
essential ways with my conclusion, since after all,
you do not prove something is so by proving that
it is not “not so.” If he prefers to consider this “not
proved” I have no objection.

Sincerely,

Lewis G. Jacobs, M.D.

316

CALIFORNIA MEDICINE

INFORMATION

Characteristics of Physicians in
California, Spring 1961

Highlights of a study being conducted
by the Bureau of Research and Planning,
California Medical Association

Twenty-six per cent of all physicians in California
as of the spring of 1961, including those working
for hire as well as private practitioners, were in gen-
eral practice whereas 44 per cent were full-time
specialists.

• Of those engaged only in private practice, 32.2
per cent were in general practice, 63.8 per cent were
in full-time specialties, and 4.0 per cent were in
part-time specialties.

• Densely populated areas have considerably
higher proportions of physicians in specialty fields
than do sparsely populated areas.

• Among full-time specialties practiced by physi-
cians (excluding those employed by the federal gov-
ernment) , the following five fields engage over 60
per cent of all specialists: Internal Medicine, Gen-
eral Surgery, Psychiatry, Obstetrics-Gynecology,
Pediatrics.

• Within private practice, the median age of full-
time specialists (45.0 years) is below that of gen-
eral practitioners (47.5 years). The average age of
part-time specialists is 53.0 years.

The foregoing data are selected from a mass of
information gathered by the C.M.A. Bureau of Re-
search and Planning in the spring of 1961 for
study of characteristics of physicians in California.

Phase One of the Bureau’s study was analysis of
information supplied in a deck of IBM cards con-
taining selected characteristics of physicians in the
state of California, which was made available by the
American Medical Association. These cards sup-
plied information on physician location, type of
practice, specialty, age, school of graduation, and a
variety of other data. Additional information about
physician characteristics, to be made available as the
study progresses, will be based on answers to a
census questionnaire completed by almost 13,000

physician respondents in late 1961 and early 1962.
These answers, combined with the basic characteris-
tics already on cards, will provide the medical pro-
fession with a wealth of information about itself.

The tables in this article contain some basic facts
about medical practice in California. Tables 1 and
2 show types of practice by county medical society
jurisdiction; Table 1 includes all physicians in the
state, and Table 2 includes only those physicians in
private practice. Table 3 shows the medical specialty
of nonfederal physicians, by type of practice. Table
4 contains an age distribution for nonfederal phy-
sicians, also by type of practice.

Table 1 : Type of Practice by County Medical Society

Jurisdiction, All Physicians

Table 1 shows the distribution of all 27,760 phy-
sicians who had California addresses as of spring,
1961. This array locates each physician geograph-
ically by county medical society jurisdiction, and
further shows numbers and per cents within each
society by type of practice. Type of practice cate-
gories are as follows: Private practice1 (further
broken down into general practice, which includes
part-time specialty, and full-time specialty) ; hos-
pital service (further broken down to distinguish
interns and residents2 from other full-time hospital
staff members) ; a third major category which in-
cludes medical school staff members, medical ad-
ministrators, nonfederal public health, physicians
practicing dentistry, and physicians employed by
industrial or insurance companies on a full-time
basis; and a fourth category which includes all
physicians who are retired or otherwise not engaged
in any kind of medical practice.

In Table 1, physicians employed by the federal
government (Veterans Administration, USPHS, and
members of the armed forces) are interspersed
according to the type of practice in which they
are engaged.

Some interesting, if obvious, facts can be de-
tected by analyzing Table 1. It is generally true that
the percentage of general practitioners in an area
is in inverse proportion to the density of the pop-
ulation of the area. Note that Inyo, Mono, Lassen,
Plumas, Modoc, Sierra, San Benito, and Tehama
counties all show per cents in general practice above
80 per cent. Conversely, low proportions of general
practitioners are found in high-density population
areas, particularly the San Francisco and Los An-
geles Metropolitan Areas. A few counties defy this
general rule due to the existence of high proportions
of physicians in fields other than private practice.

*Due to the coding system used by the A.M.A., some physicians
in federal service are included in the "Private Practice” classification.
Errors due to this coding inconsistency are negligible, however.

2See other tables for separate breakdown of interns and residents.

VOL. 97, NO. 5 • NOVEMBER 1962

317

O *£
H ►.

This is true, for example, of Napa County, where
many physicians are in hospital service and of Santa
Barbara County, which shows a high proportion
of retired physicians.

Above-average proportions of full-time specialists
seem to relate to two factors: High population
density and high incomes of the population. The rela-
tion to the former factor is evidenced in such coun-
ties as Los Angeles, Orange, Sacramento, and Santa
Clara; the relation to the latter factor in such coun-
ties as Marin, San Mateo, and Santa Barbara.

High percentages of physicians in hospital service
correlate with high population density, a fact which
appears also to be true for physicians in teaching,
research, administration, and other types of special-
ized fields.

Above-average proportions of retired physicians
are found in those counties which are generally
attractive to retired persons, such as for reasons

of climate. Among these counties are Santa Barbara,
Santa Cruz, Monterey, Riverside, and San Diego.
This category includes physicians who have never
practiced medicine in California.

The category “other hospital service” is composed
entirely of full-time salaried hospital staff members.
Napa County shows the greatest per cent of physi-
cians in this classification due to the employment
of physicians at Napa State Hospital and at Veter-
ans’ Home — a large number in relation to total
physicians in the county. This is also true of Placer
County, the site of both the Weimar Medical Center
(tuberculosis) and DeWitt State Hospital (psychi-
atric) and of Ventura County, the location of Cam-
arillo State Hospital. Solano County shows a high
percentage in this group because of the large hospi-
tal at Travis Air Force Base. The last county show-
ing over 10 per cent employed in hospitals is San
Bernardino; most of this group are staff members
at Patton State Hospital.

TABLE 2.— Type

of Practice of Physicians in Private Practice, Spring 1961

County Medical Society Jurisdiction

Total

Physicians

General Practice

Full-Time

Specialty

Part-Time Specialty

Number

Per Cent

Number

Per Cent

Number

Per Cent

Alameda-Contra Costa.

... 1,591

559

35.1

973

61.2

3.7

Butte-Glenn

53.8

43.0

3.2

Fresno

... 312

112

35.9

187

59.9

4.2

Humboldt-Del Norte

53.2

36.1

10.7

Imperial

46.2

50.0

3.8

Inyo-Mono

81.8

18.2

Kern

... 230

41.3

121

52.6

6 .1

Kings

80.0

11.4

8.6

Lassen-Plumas-Modoc-Sierra

85.7

3.6

10.7

Los Angeles

... 7,577

2,135

28.2

5,132

67.7

310

4.1

Madera

81.8

13.6

4.6

Marin

.... 246

26.0

172

69.9

4.1

Mendocino-Lake

59.0

32.8

8.2

Merced-Mariposa

60.4

30.2

9.4

Monterey

193

35.2

109

56.5

8.3

Napa

36.0

59.3

4.7

Orange

... 693

241

34.8

424

61.2

4.0

Placer-Nevada

70.0

24.3

5.7

Riverside

... 279

110

39.4

155

56.6

4.0

Sacramento-Amador-El Dorado

... 488

195

40.0

276

57.6

2.4

San Benito

84.6

7.7

San Bernardino

.... 404

157

38.9

233

57.7

3.4

San Diego

... 1,028

383

37.3

611

59.4

3.3

San Francisco

... 1,722

387

22.5

1,270

73.8

3.7

San Joaquin-Alpine-Calaveras-Tuolumne

... 245

113

46.1

122

49.8

4.1

San Luis Obispo

40.9

58.0

1.1

San Mateo

.... 560

120

21.4

430

76.8

1.8

Santa Barbara

... 245

25.3

177

72.2

2.5

Santa Clara

880

216

24.5

631

71.7

3.8

Santa Cruz

... 110

43.6

48.2

8.2

Shasta-Trinity

47.1

48.6

4.3

Siskiyou

82.6

13.0

4.4

Solano

107

49.5

47.7

2.8

Sonoma

... 177

52.0

47.5

0.5

Stanislaus

... 164

44.5

51.2

4.3

Tehama

85.0

10.0

5.0

Tulare

... 123

52.8

39.0

8.2

Ventura

... 159

42.1

53.5

4.4

Yolo

51.2

41.9

6.9

Y uba-Sutter-Colusa

44.1

52.5

3.4

State total

... 18,444

5,930

32.2

11,771

63.8

743

4.0

VOL. 97, NO. 5

NOVEMBER 1962

319

Table 2 : Type of Practice of Physicians in Private
Practice

The breakdown of physicians shown in Table 2
further delineates information contained in Table 1.
This tables enumerates only those physicians who
are actively engaged in private practice. These
18,444 general practitioners, full-time specialists,

and part-time specialists comprise slightly more
than 70 per cent of all physicians with California
addresses. Among private practitioners only, 63.8
per cent are full-time specialists, 32.2 per cent are
in general practice, and 4.0 per cent are part-time
specialists.

The variations shown in percentages among spe-

TABLE 3.' — Nonfederal Practicing Physicians1:

All Nonfederal
Physicians

Physicians in
Private Practice

General

Practice

Full-Time

Specialty

Part-Time

Specialty

Number

Per Cent

Number

Per Cent

Number

Allergy

0.3

0.4

Aviation Medicine

0.1

Anesthesiology

877

3.8

719

3.9

670

Cardiovascular

123

0.5

0.4

Dermatology

367

1.6

327

1.8

316

Gastroenterology

0.1

General Practice

7,264

31.2

5,931

32.2

5,931

Internal Medicine

3,049

13.1

2,409

13.1

2,409

Medical Administration

0.2

Neurology

0.3

0.2

Neurosurgery

178

0.8

138

0.7

136

Obstetrics-Gynecology

1,469

6.3

1,262

6.8

1,160

102

Ophthalmology

893

3.8

813

4.4

790

Orthopedic Surgery

740

3.2

632

3.4

618

Otolaryngology

369

1.6

340

1.8

336

Occupational Medicine

180

0.8

118

0.6

Pathology

514

2.2

235

1.3

224

Pediatrics

Physical Medicine and

1,289

5.5

1,030

5.6

968

Rehabilitation

0.2

Plastic Surgery

107

0.5

Psychiatry

1,529

6.6

1,030

5.6

978

Proctology

104

0.5

102

0.6

Pulmonary Disease

119

0.5

0.4

Public Health

206

0.9

Radiology

813

3.5

575

3.2

563

Surgery (General)

2,260

9.7

1,847

10.0

1,561

286

Thoracic Surgery

144

0.6

120

0.7

120

Urology

458

2.0

400

2.2

389

'll

State total 23,315 100.0

’Excludes Retired ( 1,382) and Not in Practice (336).
includes nonfederal public health, dentists, and employees of
includes all interns who have not designated a specialty.

18,444

insurance or industrial

100.0

companies.

5,931

11,771

742

TABLE 4. — Age Distribution and Median Age of

Total

General

Full-Time

Part-Time

Physicians

Practice

Specialty

Intern

Resident

Age

Number

Per Cent

Numb

er Per Cent

Number

Per Cent

Number

Per Cent

Number Per Cent

Under 30

.. 1,390

5.5

1.6

0.1

574

74.8

675

30.0

30 to 34

.. 2,729

11.0

524

8.9

736

6.2

4.5

164

21.3

1,095

48.9

35 to 39

.. 4,559

18.2

959

16.1

2,745

23.4

11.9

3.2

306

13.7

40 to 44

.. 3,916

15.7

947

16.0

2,403

20.4

12.8

0.5

4.4

45 to 49

.. 3,362

13.4

855

14.4

2,097

18.0

12.2

0.2

2.1

50 to 54

.. 2,596

10.3

766

13.0

1,450

12.3

104

14.0

0.5

55 to 59

.. 1,852

7.4

551

9.3

952

8.1

11.9

0.4

60 to 64

.. 1,439

5.8

429

7.2

656

5.5

10.5

65 to 69

. 1,125

4.5

304

5.1

422

3.6

8.7

70 to 74

762

3.0

214

3.6

172

1.4

5.2

75 and over. ....

. 1,303

5.2

287

4.8

122

1.0

8.2

Total

.. 25,033

100.0

5,930

100.0

11,771

100.0

743

100.0

768

100.0

2,243

100.0

Median age...

44.8

47.5

45.0

53.0

32.0

’Includes nonfederal public health, dentists, insurance company and industrial employees.
2Unable to compute median age.

320

CALIFORNIA MEDICINE

cialists and general practitioners are to a great extent
the same as those explained earlier in connection
with Table 1. Shown separately in Table 2, however,
are part-time specialists who were combined with
general practitioners in Table 1. This separation
alone alters the percentage relationship. Per cent
differences are somewhat accentuated in Table 2

due to the exclusion of physicians not in private
practice. These cases are most apparent in counties
which showed high proportions not in private prac-
tice in Table 1. Outstanding among these cases are
Los Angeles, San Francisco and Santa Clara coun-
ties, all of which show high proportions of interns
and residents, Napa County, which shows a high

pe of Practice by Specialty, Spring 1961

Physicians Not in

Private Practice Intern

Resident

Other

Hospital

Services

Full-Time

Medical

School

Medical

Administration

Research

Other2

Number

Per Cent Number Numbe

Number

0.1

0.2

158

3.2 2

0.9

0.8

0.2

1,333

27.4 7523

140

133

143

640

13.1 5

429

107

0.7

0.5

0.8

207

4.2

179

1.6

108

2.2

0.6

1.3

279

5.7

133

109

259

5.3 5

144

0.4

0.2

499

10.2

266

182

0.9

204

4.2

179

238

4.9

110

113

413

8.5 4

351

0.5

1.2

4,871

100.0 768

2,243

946

296

476

•Less than .05 of 1 per cent.

Note:

Per cents

may not add to 100 due to rounding.

bntederal Physicians, by Type of Practice, Spring 1961

Full-Time

Hospital

Medical

Not in

Service

School

Administration

Research

Other1

Retired

Practice

Number

Per Cent

Number Per Cent Number Per Cent N

umber

Per Cent

Number Per Cent Number

Per Cent Number Per Cent

0.7

3 1.0

11.0

3 0.6

8 2.4

8.4

28 9.5

4 7.9

20.9

19 4.0

27 8.0

220

23.3

74 25.0

3 5.8

23.0

74 15.5

45 13.3

181

19.2

64 21.6

2 4.0

22.0

65 13.6 3

0.2

33 9.9

118

12.4

44 14.9

4 7.9

6.6

61 13.0 6

0.4

30 9.0

109

11.5

35 11.9

7 13.7

6.6

75 15.7 9

0.6

24 7.1

9.3

22 7.4

9 17.6

3.3

73 15.3 24

1.7

33 9.9

6.8

14 4.7

7 13.7

3.3

52 11.0 92

6.6

43 12.7

6.0

10 3.4

8 15.7

1.1

40 8.4 177

12.9

42 12.5

1.6

2 0.6

4 7.9

1.1

12 2.5 282

20.4

21 6.2

0.8

3 5.8

1.1

2 0.4 789

57.2

30 9.0

946

100.0

296 100.0

51 100.0

100.0

476 100.0 1,382

100.0 336 100.0

44.5

43.3

58.0

39.0

51.0

55.1

VOL. 97

NO. 5

NOVEMBER 1962

321

proportion of physicians in hospital service, and
Monterey, Riverside, Santa Barbara, and Santa Cruz
Counties, which show an above-average per cent of
retired physicians.

There is no apparent uniform pattern in the geo-
graphic distribution of physicians with part-time
specialties. Only two county societies show more
than 10 per cent of private practitioners in this
category. Both of these societies are composed of
basically rural counties, although in Humboldt
County over 25 per cent of the population lives in
the city of Eureka. Counties in the San Francisco-
Oakland Metropolitan Area all show per cents of
part-time specialists below the statewide average.
Los Angeles and Orange Counties, however, show
above-average percentages. It should be observed, in
comparing these area figures to statewide averages,
that 45 per cent of all private practitioners are in
Los Angeles and Orange counties and that another
23 per cent are in the six-county San Francisco-
Oakland Metropolitan Area.

Table 3 : Specialties of Practicing Physicians by Type

of Practice

Table 3 shows the standard 28 specialty classifica-
tions for all nonfederal California physicians, for
those in private practice, and for those not in private
practice. This table indicates a more complete
breakdown of type of practice than does Table 1,
with interns, residents, medical school faculty, ad-
ministrators, physicians in research, and other phy-
sicians listed separately.

One word of caution regarding the interpretation
of Table 3: Interns are generally classified as gen-
eral practitioners in this table (see footnote 3 in
the table). This classification causes a slight over-
statement of the total number and per cent of phy-
sicans and, to a greater extent, of physicians not
in private practice who are actually in “general
practice.” It is probably also true that an excessive
number of hospital administrators and researchers
are classified as general practitioners, merely be-
cause they fit into no other classification.

In terms of the specialty classification of all non-
federal physicians in California, general practice
constitutes more than twice the number of physi-
cians found in any other single specialty. The only
other specialty which shows a figure of over 10 per
cent of total is internal medicine, with 13.1 per cent
of all physicians. Next in order are general surgery
(9.7 per cent), psychiatry (6.6 per cent), obstetrics-
gynecology (6.3 per cent), and pediatrics (5.5 per
cent) . Other specialties are each below 5 per cent of
the total.

Some interesting differences in specialties between
physicians in and not in private practice exist.

Those specialties which show the greatest differen-
tials in favor of physicians in private practice are
allergy, dermatology, ophthalmology, otolaryngol-
ogy, plastic surgery, and proctology. Conversely,
those specialties which show greater than average
numbers of physicians not in private practice are
the following: Aviation medicine, cardiovascular,
neurology, occupational medicine, pathology, psy-
chiatry, pulmonary diseases, public health, and
medical administration.

Of interest also is the composition of specialties
within the medical practice among residents and
practicing physicians. The listings below show the
rank order in terms of total numbers of physicians
in three types of practice.

Total Physicians

1. Internal medicine

2. General surgery

3. Psychiatry

4. Obstetrics-gynecology

5. Pediatrics

6. Ophthalmology

7. Anesthesiology

8. Radiology

9. Orthopedic surgery
10. Pathology

Full-Time Specialists

1. Internal medicine

2. General surgery

3. Obstetrics-gynecology

4. Psychiatry

5. Pediatrics

6. Ophthalmology

7. Anesthesiology

8. Orthopedic surgery

9. Radiology

10. Urology

Residents

1. Internal medicine

2. General surgery

3. Psychiatry

4. Obstetrics-gynecology

5. Pediatrics

6. Pathology

7. Radiology

8. Orthopedic surgery

9. Anesthesiology

10. Ophthalmology

Classifications 1 through 5 show approximately
the same ranking among the three categories. Oph-
thalmology, which ranks sixth among total physi-
cians and full-time specialists, drops to tenth position
among residents. Pathology, on the other hand,
which ranks tenth among all physicians, and does
not appear within the ten among specialists, shows
up in sixth position among residents. The four other
specialties which appear show less marked differen-
tials. Urology which ranks tenth among specialists,
is eleventh in the total ranking of residents.

Table 4: Age Distribution of Nonfederal Physicians,
by Type of Practice

Table 4 shows the age distribution and median
ages for nonfederal physicians in California, classi-
fied by type of practice. The median age for all
nonfederal physicians at the time this analysis was
made (spring 1961) was 44.8 years. This compares
with a median age for all physicians of 43.0 years,

322

CALIFORNIA MEDICINE

since many federal physicians are in younger age
groups.3

The median age for physicians in private practice
not shown in Table 4) was 46.0 years, a slightly
higher figure than for all physicians. Partial reason
for this fact is that there are more interns and resi-
dents in the distribution, which tend to lower median
age than there are retired physicians, which tend to
raise it. Since these three heterogeneous groups
comprise over half of all physicians not in private
practice and counter-balance each other, an average
age for physicians not in private practice would not
be significant.

Within private practice, the median age of full-
time specialists (45.0 years) is slightly below that
of general practitioners (47.5 years) and consider-
ably below that of part-time specialists (53.0 years) ,
with the last category showing the highest average
age by a margin of seven years over all private-
practice physicians.

Among physicians not in private practice (ex-
cluding interns, residents, and retired physicians),
medical administrators show the highest median age
(58.0 years) and physicians in research the lowest
median age (39.0 years) .

Area age differentials were calculated, but space
limitations do not allow their inclusion in this
article. The results reveal that the median physician
age was highest in rural counties (50.0 years) and
in the Santa Barbara area (49.3 years). The former
case probably represents a true distribution; the
latter is skewed by a high retired population. Rural
counties include Lake, Mariposa, Mono, Plumas,
Sierra, and Trinity. The San Jose Metropolitan Area
shows the lowest physician median age (41.7 years) ,
correlating generally with the fact that this is a
young, growing community. The median age in the
Los Angeles-Long Beach Metropolitan Area was 45.2
years; the median age in the San Francisco-Oakland
Metropolitan Area was 43.9 years.

Technical Notes

These tables represent some of the salient points
in the first phase of the Study of the Characteristics
of Physicians in California. A more detailed com-
pilation of tables will be available for distribution
in the near future. They will contain the following
information: Sex and age of all physicians, A.M.A.
membership by county medical society jurisdiction
and by type of practice, types of service of federal
service physicians, more complete breakdown by
specialties by county medical society jurisdictions,
further details as to age distribution by geographic
area, and type of practice of physicians in private
practice for counties and for county medical society

3This figure does not appear in Table 4.

jurisdictions. They can be obtained by writing to
the Bureau of Research and Planning of the Cali-
fornia Medical Association.

The Bureau of Research and Planning gratefully
acknowledges the assistance of Mr. Robert A. Enlow,
director, circulation and records department, Amer-
ican Medical Association, and his staff in supplying
the IBM cards; and to the division of research of
the California State Department of Public Health
for its generous aid in providing staff and machine-
time for the analyses and tabulations presented.
Among the several individuals who have assisted in
this task are: Robert Dyar, M.D., Louis F. Saylor,
M.D., and Miss Jean Bowman. The services of Mr.
Gordon Elmeer, an epidemiological trainee, were
also made available to the bureau by the division.

California Medical Association, 693 Sutter Street, San Francisco 2.

Use of, and Satisfaction with, C.M.A.
Relative Value Studies by Physicians in
Active Practice in California

A Report by the Bureau of Research and
Planning, California Medical Association

Data tabulated from the Study of the Character-
istics of Physicians in California, conducted by
the C.M.A. Bureau of Research and Planning,
show that over 70 per cent of all physicians in ac-
tive private practice utilize the Relative Value
Studies, with over 41 per cent stating that they use
it “all or most of the time.” Use figures range from
almost 78 per cent of physicians who participate in
some form of prepayment program to under 53 per
cent of physicians who do not participate in any
such program.

Eighty per cent of all physicians in private prac-
tice who use the RVS expressed general satisfac-
tion, with 11.8 per cent dissatisfied and 8.2 per cent
stating no opinion as to their satisfaction. Of the
80 per cent who expressed satisfaction, two out of
three use the RVS all or most of the time.

The following analyses discuss the use by phy-
sicians in California and their satisfaction with the
C.M.A. Relative Value Studies. The information is
based upon data collected by the Bureau of Research
and Planning in the Fall of 1961. It is the first group
of data to be tabulated from the almost 13,000
responses to the Study of Characteristics of Physi-
cians in California, a census questionnaire sent to
all physicians in the State as of Spring, 1961.

A total of 11,910 responses were used in compil-
ing the tables shown below. Responses which were

VOL. 97, NO. 5 • NOVEMBER 1962

323

not used included the following: retired, not in the
active practice of medicine, no longer living in
California, and physicians with California addresses
who actually reside overseas (APO and FPO San
Francisco addresses).

Table 1 shows the proportion of physicians in
private practice within the State who use the Rela-
tive Value Studies. Slightly over 70 per cent of all
such physicians state that they make use of the
RVS, with such usage ranging from “all or most
of the time” to “only in specific cases or programs.”
The former group comprises 41.7 per cent of phy-
sicians, whereas the latter comprises 10.7 per cent.
The group stating that they use the RVS “occa-
sionally” makes up 18.5 per cent of the respondents,
with the “non-users” accounting for the remaining
29.7 per cent.

Among those physicians who use the RVS all
or most of the time, over 90 per cent expressed
general satisfaction. Two hundred thirty-nine re-
spondents (2.6 per cent of the overall total) stated
that they are dissatisfied with the RVS but neverthe-
less use it all or most of the time. Satisfaction ratios
seem to be correlated with amount of usage, with
69.3 per cent of those who use the RVS “occasion-
ally” and 57.2 per cent of those who use the RVS
“only for specific cases or programs” stating that
they found the structure and performance of the
RVS satisfactory.

Table 2 shows a breakdown of all physicians who
use the RVS, in terms of their general satisfaction
with it. Eighty per cent of all physicians who use
the RVS expressed satisfaction with its structure and
performance, with 66.4 per cent of the satisfied

TABLE 1. — Use of and Satisfaction with the Relative Value
Studies by All Physicians*

Nature of
Response

Number

Respond-

ents

Per Cent
of All
Respond-
ents

Per Cent
of

Satisfac-
tion by
Frequency
of Use

Total respondents

9,061

100.0

Do not use

2,688

29.7

Use all the time

3,726

41.1

100.0

Satisfied

3,377

37.3

90.6

Not satisfied

239

2.6

6.4

No opinion

110

1.2

3.0

Use occasionally

1,680

18.5

100.0

Satisfied

1,164

12.8

69.3

Not satisfied

277

3.1

16.5

No opinion

239

2.6

14.2

Use only in specific

cases 967

10.7

100.0

Satisfied

553

6.1

57.2

Not satisfied

238

2.6

24.6

No opinion

176

2.0

18.2

•Overall total response by 11,910 physicians includes 2,849 physi-
cians not in private practice or who did not answer question regard-
ing RVS usage.

group stating that they use the RVS all or most of
the time. Under 12 per cent of all users indicated
dissatisfaction; over two out of three physicians in
the dissatisfied group stated that they use the RVS
only “occasionally” or “for specific cases or pro-
grams.” Users who expressed no opinions as to their
satisfaction accounted for the remaining 8.2 per
cent of the group. Only two in five of the “no opin-
ion” group are constant users- of the RVS.

Tables 3 and 4 show percentages of usage of, and
satisfaction with, the RVS for physicians in private

TABLE 2. — Satisfaction with and Frequency of Use
All Physicians in Private Practice Who Use the

of RVS by
RVS

Number

Per Cent

Frequency
of Use by

of All

Degree of

Nature of

Respond-

Satisfac-

Response

ents

tion

Total using RVS

... 6,373

100.0

Satisfied

... 5,094

80.0

100.0

Use all the time

... 3,377

53.0

66.4

Use occasionally

... 1,164

18.3

22.8

Use only in specific

cases

... 553

8.7

10.8

Not satisfied

... 754

11.8

100.0

Use all the time

... 239

3.7

31.7

Use occasionally

... 277

4.4

36.8

Use only in specific
cases

... 238

3.7

31.5

No opinion

... 525

8.2

100.0

Use all the time

... 110

1.7

21.0

Use occasionally

... 239

3.7

45.6

Use only in specific
cases

... 176

2.8

33.4

TABLE 3. — Satisfaction and Frequency of Use of RVS by Physi-
cians in Private Practice Who Participate in any Prepayment
Program

Total

Responding
to Questions
Concerning
RVS

Number

Respond-

ents

Per Cent
Using
RVS and
Per Cent
Satisfaction
of RVS
Users

Per Cent
Use by
Degree of
Satisfac-
tion

Total responding

.... 6,324

100.0

Do not use RVS

.... 1,406

22.2

Use RVS

.... 4,918

77.8

Total using RVS

.... 4,918

100.0

Satisfied

.... 4,037

82.1

100.0

Use all the time

.... 2,731

55.6

67.7

Use occasionally

.... 886

18.0

21.9

Use only in specific
cases

.... 420

8.6

10.4

Not satisfied

.... 514

10.5

100.0

Use all the time

.... 174

3.5

33.9

Use occasionally

.... 190

3.9

36.9

Use only in specific
cases

.... 150

3.1

29.2

No opinion

.... 367

7.4

100.0

Use all the time

1.5

20.7

Use occasionally

.... 170

3.4

46.3

Use only in specific

cases 121 2.5 33.0

324

CALIFORNIA MEDICINE

TABLE 4. — Satisfaction and Frequency of Use of RVS by Physi-
cians In Private Practice Who Do Not Participate In Any
Prepayment Program

Total Responding
to Questions
Concerning RVS

Number

Respond-

ents

Per Cent
Using
RVS and
Per Cent
Satisfaction
of RVS
Users

Per Cent
Use by
Degree of
Satisfac-
tion

Total respondents

.... 2,671

100.0

Do not use RVS

... 1,258

47.1

Use RVS

.... 1,413

52.9

Total using RVS

.... 1,413

100.0

Satisfied

.... 1,023

72.4

100.0

Use all the time

.... 625

44.3

61.1

Use occasionally

.... 269

19.0

26.3

Use only in specific
cases

.... 129

9.1

12.6

Not satisfied

.... 237

16.8

100.0

Use all the time

.... 64

4.5

27.0

Use occasionally

6.1

36.3

Use only in specific
cases

.... 87

6.2

36.7

No opinion

.... 153

10.8

100.0

Use all the time

.... 33

2.3

21.6

Use occasionally

.... 67

4.7

43.8

Use only in specific
cases

.... 53

3.8

34.6

practice who participate in some form of prepay-
ment program and for those who do not participate
in any such program. Whereas almost 80 per cent
of physicians in the former group use the RVS,
under 53 per cent in the latter group do so. Of users
only, 82.1 per cent of program participants find the
RVS satisfactory and 10.5 per cent are dissatisfied;
the percentages for non-participants are 72.4 and
16.8 respectively.

Of the 6,324 responses enumerated in Table 3,
it is of interest that 6,089 were from participants in
Blue Shield and/or Foundations for Medical Care
or other physician-sponsored Foundations.

The foregoing data represent responses from al-
most 50 per cent of all physicians in private prac-
tice in California. Although the characteristics of
the respondents, such as age and medical specialty,
have yet to be compared with those of all physicians
in private practice, the high rate of response suggests
that these data are generally representative of the
universe.

California Medical Association, 693 Sutter Street, San Francisco 2.

VOL. 97, NO

NOVEMBER 1962

325

' / Vie continued achievement of high standards of patient care in the preventive, curative, and
JL restorative aspects of illness depends upon a harmonious, collaborative relationship between
medicine and nursing . In an effort to protect and foster an enduring alliance of understanding and
cooperation between these 2 major health professions, the Committee on Nursing has instituted a
continuing program of liaison, communication, education, and research. The Committee has author-
ized publication of the following report on its objectives and program.

Veronica L. Conley, Ph.D., Secretary

Objectives and Program of the
A.M.A. Committee on Nursing

The program of the A.M.A. Committee on Nurs-
ing is based on three general assumptions: (1) that
nurses have a separate and distinct professional
status and their contributions are those of co-work-
ers; (2) that nursing should expect the medical
profession to support and endorse high standards of
nursing education and service; and (3) that each of
the various levels of academic and technical accom-
plishment in nursing makes its own unique contri-
bution to the total health care of the public.

On the basis of these broad assumptions, the Com-
mittee has adopted the following objectives:

1. To expand and strengthen liaison activities between
organizations representing the medical and nursing profes-
sions at the national, state, and local levels.

Liaison has been established with all the major nursing
organizations (including the American Nurses’ Association,
the National League for Nursing, the National Federation
of Licensed Practical Nurses, the National Association for
Practical Nurse Education and Service, and others) as well
as with constituent and component medical associations,
medical specialty groups, and several national organizations
with a collateral interest in nursing.

The Committee feels that one of its major contributions
is to promote interprofessional conferences between physi-
cians and nurses. A committee composed of A.M.A. and
A.N.A. representatives is now planning a conference on
nurse-physician aspects of professional practice. The Com-
mittee on Nursing will also encourage the inclusion of nurses
on programs of national and state medical meetings and
attempt to remedy the scarcity of positively oriented, un-
biased material on nursing in the medical literature.

2 .To study and report to the medical profession on cur-
rent practices and trends in nursing and on developments
among nursing auxiliary personnel.

Through its headquarters staff, the Committee is collect-
ing information on nursing matters vital to physicians. A
file of abstracts, excerpts, and reprints is available for quick
reference.

3. To stimulate, initiate, and, where feasible, support re-
search in areas pertinent to the nurse-physician relationship
in professional practice.

Such research requires the collaboration of many disci-
plines. Several nurse-physician teams are now engaged in

Reprinted from The Journal of the American Medical Association,
181:430, August 4, 1962. Copyright 1962, by the American Medi-
cal Association.

extensive research projects. These include studies of inter-
disciplinary participation in planning care; the nursing
needs of chronically ill ambulatory patients; and the amount
and type of nursing service which makes the maximum
contribution to maternal and infant welfare.

4 .To offer advisory services to both professions on inter-
professional matters.

The secretary and chairman of the Committee serve at
present on the committee on careers of the National League
for Nursing. The secretary is also a member of the advisory
council of the National Federation of Licensed Practical
Nurses, the National League for Nursing’s committee to
study costs of nursing education, and the hospital advisory
council of the National Association for Practical Nurse
Education and Service. The Committee will also serve as
a consultant group to committees, councils, and depart-
ments within the A.M.A. Similar services have been offered
to constituent and component medical associations.

5 .To provide support and assistance to the nursing pro-
fession and its nonprofessional auxiliary personnel in their
efforts to maintain high standards.

Nursing, like medicine, is faced with pressing demands
for change if high standards are to be maintained in our
present environment of rapid scientific and social advances.
Nursing is now engaged in a continuous reevaluation of its
educational system, its scope of services, its legal responsi-
bilities, and other phases of its practice which reflect in the
quality of patient care. This Committee supports the efforts
of the nursing profession in maintaining high standards
and offers its cooperation and assistance.

6 .To encourage physicians to accept invitations to serve
on nursing school faculties.

In view of growing pressures on the professional nurse
to assume responsibilities of a medical nature, the teaching
role of the physician warrants reevaluation. At the present
time, some nursing schools are finding it necessary to assign
nurse faculty members to lecture on medical subjects.

If the medical and nursing professions are to make
the fullest use of their joint potential, they must have
not only a common denominator of interest in the
patient and a comparable body of knowledge, but
also the kind of relationship that derives from a
deeper appreciation of, and respect for, each other as
allies working toward the same goals.

C. H. Benage, M.D. Charles L. Leedham, M.D.

Elias S. Faison, M.D. William R. Willard, M.D.

Benson W. Harer, M.D. Arthur A. Kirchner, M.D.

Chairman

326

CALIFORNIA MEDICINE

NEWS & NOTES

NATIONAL • STATE • COUNTY

ALAMEDA

Dr. Charles E. Smith, dean of the University of Cali-
fornia School of Public Health, Berkeley, has been awarded
the Bronfman Prize for Public Health Achievement by
the American Public Health Association. He was cited as
an “eminent scientist, public health statesman and inspiring
teacher, a great leader in man’s war against disease and
disability.”

The award was presented at the recent annual meeting of
the A.P.H.A. by Dr. Charles Glen King, association president.
* * *

Dr. Lester Breslow, chief of the Division of Preventive
Medical Services of the State Department of Public Health,
has been named chairman of the American Cancer Society’s
Advisory Committee on Research on the Etiology of Cancer.
He will serve until August, 1963.

LOS ANGELES

Dr. James V. McNulty has been elected president of the
State Board of Medical Examiners. Dr. McNulty has been
on the board since 1960.

♦ * £

Dr. Carroll J. Beilis of Long Beach has been appointed
professor and chairman of the department of surgery at the
California College of Medicine, it has been announced by
Dr. Benjamin B. Wells, dean of the Los Angeles medical
school. Dr. Beilis, who received his M.D. degree at the Uni-
versity of Minnesota in 1936, received a Ph.D. degree there
in 1941 and was instructor in surgery at the university’s
medical school before entering private practice in California.

* * *

Dr. Stafford L. Warren, vice chancellor of health sci-
ences at University of California, Los Angeles, has been
appointed to the National Advisory Health Council for a
four-year term.

In his new post he will advise the Surgeon General on
matters relating to health activities, training grants and
career award programs.

* # *

The Childrens Hospital of Los Angeles will hold the

First Clinical Conference in Pediatric Anesthesiology on
January 26, 27, 1963. The two-day program will be devoted
to the practical aspects of the preanesthetic, anesthetic, and
postanesthetic management of infants and children. A model
operating room will demonstrate modern anesthesia equip-
ment and monitors.

Guest faculty will include Doctors Leonard Bachman,
M. Kathleen Belton, and Robert M. Smith.

Further information may be obtained from Dr. M. Digby
Leigh, Childrens Hospital, 4614 Sunset Boulevard, Los

Angeles 27.

* * *

The Fourth National Conference on the Medical
Aspects of Sports sponsored by the American Medical
Association, under the auspices of the A.M.A. Committee

on the Medical Aspects of Sports, will be held in Los
Angeles at the Statler Hilton Hotel on November 25, 1962.
The Conference will be held in conjunction with the Clinical
Meeting of the American Medical Association, November
25-28, 1962.

SAN FRANCISCO

Dr. John B. Schaupp has been elected president-elect
of the San Francisco Medical Society. Dr. George K.
Herzog, Jr., was elected secretary. Dr. Alexander F.
Fraser was elected treasurer and Dr. John B. Bryan was
elected editor.

* * *

The 1962 Albert Lasker Award in Basic Medical Research
was won by Dr. C. H. Li, professor of biochemistry at
Berkeley and director of the Hormone Research Laboratory
associated with the University’s School of Medicine in San
Francisco.

Dr. Li won his award for the isolation and identification
of six of the hormones of the anterior pituitary gland,
including ACTH and the human growth hormone.

* * *

Dr. Alex L. Finkle, associate clinical professor of urology
at University of California School of Medicine, San Fran-
cisco, recently received a grant of $85,000 from the U.S.
Public Health Service for support of a study of abnormal
blood flow in obstructive kidney disease.

GENERAL

Peacetime veterans with non-compensable service-con-
nected disabilities who have just become eligible for Veter-
ans Administration medical and dental treatment, under
a new law, must secure approval from the nearest VA reg-
ional office or hospital before they go to private physicians
and dentists for treatment at VA expense, acording to an
announcement by the Veterans Administration.

For more information about benefits under the new law,
or to make application for VA medical, dental or hospital
care, peacetime veterans should contact the nearest VA
regional office or hospital.

Plans for certification examinations for medical
assistants are being made by the American Association of
Medical Assistants following the formative meeting of a
certifying board composed of physicians, educators and med-
ical assistants. Purpose of the certification plan is to make
the assistants better qualified for service in physicians’
offices.

Mary Kinn, Santa Ana, chairman of the board, announced
that examinations will be given simultaneously in Kansas,
California and Miami Beach immediately preceding next
year’s annual meeting of the association. Professional assist-
ance will be secured for administering and grading the
examinations, Mrs. Kinn said.

At the recent annual meeting of the association in Detroit,
two publications put out by California’s medical assistants
were awarded top national honors. California Medical As-
sistant, official state publication of the C.M.A.A., edited by
Mrs. Donna C. Goodland of Saratoga, was judged best of
the state journals. The Long Beach chapter’s The Quill,
edited by Patricia Laird, was named the best in the nation
among the chapter publications.

* * *

The Council on Undergraduate Medical Education of
the American College of Chest Physicians, which is to hold
its interim clinical meeting November 24 and 25 in Los

VOL. 97, NO. 5

NOVEMBER 1962

327

Angeles, is offering three cash awards to be given annually
for the best contribution prepared by undergraduate medical
students on any phase of the diagnosis or treatment of
chest diseases (heart or lungs) .

The official application form and additional information
may be obtained from Mr. Murray Kornfeld, Executive
Director, American College of Chest Physicians, 112 E.
Chestnut St., Chicago 11, 111.

•H »£

Dr. Sol R. Baker, Los Angeles, was elected president
of the American Cancer Society’s California Division at the
recent annual meeting of the organization.

Dr. John W. Cline of San Francisco, president of the
Cancer Advisory Council, was awarded the Cancer Society’s
bronze medal.

Dr. David A. Wood, San Francisco, was elected an
honorary life member of the National Board of Directors
of the American Cancer Society at its recent meeting in New
York City.

EDUCATION NOTICES

POSTGRADUATE

UNIVERSITY OF CALIFORNIA AT LOS ANGELES

Lower Extremities Prosthetics. Monday through Fri-
day. December 10 through 14. Fee: $125. 40 hours.

Selected Topics in Pharmacology and Therapeutics.
Friday and Saturday. January 11 and 12. Fee: $50. 12
hours.

Workshops in the Clinical Use of Radioisotopes.

Alternate Wednesday afternoons. January 23 through
May 22. 20 hours.*

Surgical Anatomy. Wednesday evenings. January 23
through March 27. Fee: $50. 20 hours.

Common Problems in Dermatology. Thursday after-
noons. February 14 through March 21. Fee: $50. 12
hours.

Clinical Postgraduate Program in Mexico City. Feb-
ruary 20 to March 2. Fee: $100. 18 hours.

Proctology and Sigmoidoscopy. Thursday through Sat-
urday. February 21 through 23. Fee: $60. 15 hours.

Clinical Traineeships. Anesthesia, Dermatology, Pedi-
atrics, Anatomy, Radioisotopes and Urology. Dates to
be arranged. 2 weeks: $150; 4 weeks: $250. Minimum
period, 2 weeks.

For information on courses for physicians or ancillary per-
sonnel contact: Thomas H. Sternberg, M.D., Assistant
Dean for Department of Continuing Education in Medi-
cine and Health Sciences, U.C.L.A. Medical Center, Los
Angeles 24. BRadshaw 2-8911, Ext. 2115.

UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

Practical Management of Problems in Adolescent
Medicine. Saturday. November 3. Children’s Hospital,
San Francisco. Fee: $15. 6% hours.

Problems in EKG Interpretation. Saturday and Sun-
day. November 3 and 4. Fee: $40. 12 hours.

Clinics in Dermatology. Saturday and Sunday, Novem-
ber 10 and 11. Fee: $45. 13 hours.

Psychiatry in General Practice — A Clinical Workshop.
Saturday and Sunday. November 17 and 18. Napa State
Hospital. Fee: $20. 11 hours.

Changing Concepts of Diagnosis and Management
of Vascular Disease. Saturday and Sunday. November
17 and 18. Fee: $40. 12% hours.

Clinical Applications of Symptoms and Signs. Friday
through Sunday. November 30 through December 2.
Fee: $10 each %-day session, $50 all sessions. 19 hours.

The Neck and Shoulder Girdle. Friday and Saturday.
November 30 and December 1. Fee: $40. 14 hours.

Practical Electrocardiography. Friday and Saturday.
November 30 and December 1. Franklin Hospital, San
Francisco. Fee: $40. 12% hours.

Psychiatric Perspectives in Medicine. Saturday and
Sunday. December 1 and 2. Stockton State Hospital.
Fee: $15. 14 hours.

Ocular Pharmacology and Therapeutics. Thursday
through Saturday. December 6 through 8. Fee: $60. 18
hours.

Puberty and the Climactic. Friday and Saturday. De-
cember 7 and 8. Fee: $40. 12 hours.

The Initial Clinical Impact (The Physician and the
Emotionally Disturbed Patient) . Thursday through Sat-
urday. December 13 through 15. Langley Porter Neuro-
psychiatric Institute. Fee: $45. 14% hours.

The Pediatric Chest. Saturday. January 12. Children’s
Hospital, San Francisco. Fee: $15. 6% hours.

Clinics in Daily Practice. Friday through Sunday. Jan-
uary 18 through 20. Fee: $10 each %-day session. $50
all sessions.

Recent Advances in Drug Therapy. Saturday and Sun-
day. February 9 and 10.*f

Neuropsychiatry and General Practice. Napa State
Hospital. Thursday evenings. February 14 through
March 21. Fee: $10. 12 hours.

Clinical Neurology. Friday through Sunday. February
15 through 17. *f

Course for Physicians in General Practice. Monday
through Friday. February 25 through March 1. Mount
Zion Hospital, San Francisco. *f

Courses presented by Special Arrangement (continu-
ously) :

1. Principles and Clinical Uses of Radioisotopes

(full time for one to three months).

2. Anesthesiology (full time for one to three weeks).

For information on courses for physicians or ancillary per-
sonnel contact: Seymour M. Farber, M.D., Assistant
Dean, Department of Continuing Medical Education in
Medicine and Health Sciences, University of California
Medical Center, Room 565-U, San Francisco 22. MOnt-
rose 4-3600, Ext. 179.

* Fees to be announced.
tHours to be announced.

328

CALIFORNIA MEDICINE

UNIVERSITY OF SOUTHERN CALIFORNIA,

LOS ANGELES

Advanced Home Course in Electrocardiography. One
year postgraduate series, electrocardiogram interpreta-
tion by mail. Fifty-two issues: $85. Physicians may
register at any time.

Symposium on Neoplastic Diseases (Homecoming).
Thursday and Friday. November 1 and 2. Ambassador
Hotel. Fee: $25.

Psychiatry in Medical Practice. Saturday and Sun-
day. November 17 and 18. Santa Barbara County
General Hospital. Fee: $25.

Electrocardiographic Interpretation. Thursday
through Saturday. December 6 through 8. Statler-
Hilton Hotel, Los Angeles.* t

1963

Psychiatry in Medical Practice. January 12 and 13.
Two-day intensive workshop. San Bernardino County
General Hospital. Fee: $35.

Pediatric Psychiatry for General Practitioners and
Pediatricians. January 30 through April 10. Psychi-
atric Unit, Los Angeles County General Hospital. Fee:
$35.

Psychiatry Case Conferences for Medical Practi-
tioners. January 30 through April 10. Eleven sessions,
to be held simultaneously at St. John’s Hospital, Santa
Monica; Orange County General Hospital, Orange;
Memorial Hospital of Long Beach; Cedars of Lebanon
Hospital. Fee: $40.

Contact: Phil R. Manning, M.D., Associate Dean and
Director, Postgraduate Division, University of Southern
California School of Medicine, 2025 Zonal Avenue, Los
Angeles 33. CApital 5-1511.

Psychiatry Courses. Contact: Allen J. Enelow, M.D.,
Associate Clinical Professor, Department of Psychiatry,
1934 Hospital Place, Los Angeles 33, CA 5-3131, Ext.
71951.

LOMA LINDA UNIVERSITY

1. Anesthesia. Six months. 250 to 300 hours. Fee:

$350.

2. Pulmonary Diseases (can be arranged).

Continuously: Illustrated Medical Lectures. Thirty-

PRESBYTERIAN MEDICAL CENTER

Gastroenterology. Saturday, November 10. 7 hours.

Fee: $254

Pediatrics. Saturday, December 1. 7 hours. Fee: $254
Diabetes and Thyroid. Saturday, January 12, 1963. 7
hours. Fee: $254

Arteriosclerosis. Saturday, January 19, 1963. 7 hours.
Fee: $254

Dermatology. Saturday, February 2, 1963. 7 hours. Fee:
$254

Operable Heart Disease. Friday and Saturday. March
1 and 2, 1963. 14 hours. Fee: $25.

Keratoplasty. Wednesday through Friday. March 6
through 8.*f Contact: Secretary of the Eye Bank, Pres-
byterian Medical Center.

Office Diagnosis. Saturday, March 9, 1963. 7 hours.
Fee: $254

Cancer. Saturday and Sunday. March 16 and 17, 1963.
14 hours. Fee: $25.

Fractures: “4-R’s.” Saturday, March 23, 1963. 7 hours.

Fee: $254

Minor Surgery: Office and Hospital. Saturday, April
6, 1963. 7 hours. Fee: $254

Contact: Arthur Selzer, M.D., Chairman, Education Com-
mittee, Presbyterian Medical Center, Clay & Webster
Streets. San Francisco 15. WEst 1-8000.

CALIFORNIA MEDICAL ASSOCIATION
POSTGRADUATE CIRCUIT COURSES

A Symposium on the New Views of Hypertension.
By the faculty from the University of California Medi-
cal Center, San Francisco. Friday, January 18. Sister’s
Hospital, Santa Maria. Chairman: Clifford E. Case,
M.D., P.O. Box 315, Santa Maria.

A Symposium on the New Views on Hypertension.
By the faculty from the University of California Medi-
cal Center, San Francisco, in cooperation with San Luis
Obispo County Medical Society. General Hospital, San
Luis Obispo. Saturday, January 19. Chairman: Henry
A. Zevely, M.D., 878 Boysen Avenue, San Luis Obispo.
California Medical Association Postgraduate Insti-
tutes— 1963.

Southern Counties. In cooperation with Loma Linda
University School of Medicine. Thursday and Friday.
February 7 and 8. El Mirador Hotel, Palm Springs.
Chairman: Andrew 0. Fitzmorris, M.D., 1701 North
Palm Canyon, Palm Springs.

W est Coast Counties. In cooperation with UCLA School
of Medicine. Thursday and Friday. March 7 and 8.
Del Monte Lodge, Pebble Beach. Chairman: James
D. Niebel, M.D., Suite 409, Professional Building,
Monterey.

North Coast Counties. In cooperation with USC School
of Medicine. Thursday and Friday. April 4 and 5.
Hoberg’s Resort, Lake County. Chairman: Richard
C. Barnett, M.D., 450 Pitt Avenue, Sebastopol.

San Joaquin Valley Counties. In cooperation with Stan-
ford University School of Medicine. Thursday and
Friday. May 30 and 31. Ahwahnee Hotel, Yosemite.
Chairman: Thomas J. Fuson, M.D., 2944 Fresno
Street, Fresno.

tThese courses will be offered at $25 per course or 4
courses for $80 or 8 courses for $120.

VOL, 97, NO. 5

NOVEMBER 1962

329

Sacramento Valley Counties. In cooperation with Uni-
versity of California School of Medicine, San Fran-
cisco. Friday and Saturday. June 28 and 29. (Place
to be announced.) Chairman: A. John Quinn, M.D.,
2600 Capitol Avenue, Suite 312, Sacramento 16.

i i i

AUDIO-DIGEST FOUNDATION

Audio-Digest Foundation, the California Medical Asso-
ciation’s nonprofit subsidiary organized for the practic-
ing physician’s continuing postgraduate medical edu-
cation, has released its 1962 Catalog of Classics.
Representing tape-recorded highlights of the past year’s
most significant medical meetings (American Medical
Association, American College of Physicians, American
Society of Anesthesiologists, American College of Ob-
stetricians and Gynecologists, and dozens of university
postgraduate courses) the new Catalog lists 355 one-
hour tape-recordings representing all areas of medical
practice. Copies of the catalog and information con-
cerning continuing subscriptions to Audio-Digest
programs (General Practice, Obstetrics-Gynecology,
Anesthesiology, Pediatrics, Internal Medicine and Sur-
gery and a prospective new service in Ophthalmology-
Otorhinolaryngology) may be obtained by writing to
Claron L. Oakley, Editor, 618 South Westlake Avenue,
Los Angeles 57.

Medical Dates Bulletin

American Rhinolocic Society 8th Annual Meeting.
Statler Hilton Hotel, Los Angeles. November 1 and 2.
Contact: American Rhinologic Society, 530 Hawthorne
Place, Chicago 13.

TB & Health Association of Los Angeles County
Symposium on the Techniques of Teaching Diseases of
the Chest. November 3. Sheraton West Hotel, Regency
and Wedgewood Rooms, Los Angeles. 8:30 a.m. to
3:30 p.m. Contact: Oscar J. Balchum, M.D., chairman,
Planning Committee, c/o TB & Health Assoc, of Los
Angeles County, 1670 Beverly Blvd., Los Angeles 26.

American Otorhinolocic Society for Plastic Surgery,
Inc. November 9 through 13. Ambassador Hotel, Los
Angeles. Contact: Joseph G. Gilbert, M.D., secretary,
75 Barberry Lane, Roslyn Heights, N. Y.

California Conference of Local Health Officers
Biannual Meeting. Riverside County Health-Finance
Building. November 13-14. Contact: Wm. Allen Long-
shore, Jr., M.D., asst, chief. Division Community Health
Services, State Dept, of Public Health, Berkeley.

San Diego Chapter of California Academy of Gen-
eral Practice, 7th Annual Las Vegas Meeting. No-
vember 15 through 18. Flamingo Hotel, Las Vegas.
9:00 a.m. to 3:00 p.m. Contact: Edwin N. Reithmayer,
M.D., 1115 W. Chase, El Cajon.

Los Angeles Orthopedic Hospital and USC School
of Medicine Symposium. “Hip Problems in Children.”
Orthopedic Hospital, Los Angeles. November 24, 8:30
a.m. to 4:30 p.m. Contact: J. Vernon Luck, M.D., and
Robert Mazet, M.D., chairmen. Orthopedic Hospital,
2400 South Flower Street, Los Angeles 7.

American Collece of Chest Physicians (Interim Ses-
sion) . November 24 and 25. Ambassador Hotel, Los An-
geles. Contact: Mr. Murray Kornfeld, executive director,
112 E. Chestnut Street, Chicago 11.

Coordinators of Cancer Teaching. November 24 and
25. Sheraton Huntington, Pasadena, Saturday, 8:00
p.m. Los Angeles General Hospital, Sunday, 9:15
a.m. Contact: Lewis W. Guiss, M.D., secretary, Depart-
ment of Surgery, USC School of Medicine, Los An-
geles.

American Medical Association National Conference
on the Medical Aspects of Sports. Statler Hilton
Hotel, Los Angeles. Sunday, November 25. Contact:
Fred V. Hein, Ph.D., secretary, A.M.A. Committee on
the Medical Aspects of Sports, 535 N. Dearborn Street,
Chicago 10, 111.

American Medical Association Clinical Meeting, Bilt-
more Hotel, Los Angeles. November 25 through 28.
Contact: F. J. L. Blasingame, M.D., executive vice-
president, 535 N. Dearborn, Chicago 10.

American Medical Women’s Association, Ambassador
Hotel, Los Angeles. November 29 through December 2.
Contact: Jessie Laird Brodie, M.D., executive director,
1790 Broadway, New York 19.

West Coast Allercy Society, Annual Meeting. Decem-
ber 1. Portland, Oregon. Contact: Mr. J. M. Chesebro,
executive secretary, 1818 S.E. Division Street, Portland.

Scripps Clinic and Research Foundation, Institute
for Cardiopulmonary Diseases. “Cardiology: Physi-
ology and Biochemistry.” December 4 to 7. Sherwood
Hall, La Jolla. Fee: AAC Members $50. Non Members
$100. Contact: Harold M. Lowe, M.D., 476 Prospect
Street, La Jolla.

Los Angeles Pediatric Society Arthur H. Parmelee
Lecture. January 9, 6:30 p.m. Ambassador Hotel, Los
Angeles. Contact: Leslie M. Holve, M.D., vice presi-
dent, 1015 Gayley, Los Angeles 24.

Fresno County Heart Association, Central California
Physicians’ Cardiovascular Symposium. January 18,
9:00 a.m. to 5:00 p.m. Contact: J. A. Polhemus, M.D.,

1963 MEETINGS

330

CALIFORNIA MEDICINE

chairman, Professional Services Committee, 1921 East
Belmont Street, Fresno.

Orange County Heart Association 8th Annual Sympo-
sium on Cardiovascular Disease. Disneyland Hotel.
January 19. Contact: Howard G. Buswell, executive di-
rector. P.O. Box 1704, Santa Ana.

American Thoracic Society. “The Evaluation of Pul-
monary Function.” January 21 through 25. UC Medical
Center, San Francisco. Co-sponsors: Tuberculosis and
Health Association of California, California Thoracic
Society, UC School of Medicine, Stanford University
School of Medicine and California Department of Pub-
lic Health. Fee: ATS members $75. Non members $100.
Contact: John R. Goldsmith, M.D., chairman, Pulmo-
nary Function Course Planning Committee, 130 Hayes
Street, San Francisco 2.

First Clinical Conference on Pediatric Anesthesia.
Children’s Hospital, Los Angeles. January 26 and 27.
Contact: M. Digby Leigh, M.D., 4614 Sunset Boulevard,
Los Angeles 27.

Institute for Metabolic Research IItii Annual Ses-
sion. “Dynamics of Endocrine and Metabolic Diseases.”
February 11 through 13. Highland-Alameda County
Hospital, Main Auditorium, Oakland. Contact : L. W.
Kinsell, M.D., director, Institute for Metabolic Research.

Los Angeles County Medical Association, 8th Spring
Postgraduate Meeting. Statler Hitlon Hotel, Los An-
geles. February 16 and 17. Contact: T. W. McIntosh,
M.D., 686 E. Union Street, Pasadena.

Los Angeles County Heart Association, Midwinter
Symposium on Heart Disease. Ambassador Hotel, Los

Angeles, February 27, 9:00 a.m. to 4:00 p.m. Contact:
Mr. Chauncey A. Alexander, executive director, 2405
West 8th Street, Los Angeles 57.

I.oma Linda University School of Medicine Alumni
Postgraduate Convention. March 3 through 7. Re-
fresher Courses: March 3 and 4, 8:00 a.m. to 12:00
noon; 2:00 p.m. to 5:00 p.m. White Memorial Medical
Center. Scientific Assembly: March 5 through 7, Am-
bassador Hotel. Contact: Jack Hallatt, M.D., general
chairman, 316 N. Bailey St., Los Angeles 33.

American Board of Surgery. 13th Annual Postgraduate
Medical and Surgical Assembly. Pioneers Memorial
Hospital, Brawley. March 15 and 16. Contact: Wayne
E. Garrett, M.D., 528 G. Street, Brawley.

International College of Applied Nutrition, Third
Annual Convention. Huntington-Sheraton Hotel, Pasa-
dena. March 21 and 22. Contact: Donald C. Collins,
M.D., international secretary-general, 7046 Hollywood
Boulevard, Suite 503, Hollywood 28.

California Medical Association Annual Session.

March 23 through 27. Ambassador Hotel, Los Angeles.
House of Delegates convenes March 23. Scientific Pro-
gram begins March 24. Contact: John Hunton, execu-
tive secretary, California Medical Association, 693
Sutter Street, San Francisco 2.

American Academy of Pediatrics, Spring Session. Stat-
ler Hilton Hotel, Los Angeles. April 22 to 24. Contact:
W. J. Becker, business manager, 1801 Hinman Avenue,
Evanston, Illinois.

American Gastroenterological Association. May 30
through June 1. Fairmont Hotel, San Francisco. Con-
tact: Wade Volwiler, M.D., Department of Medicine,
University of Washington, Seattle.

■

VOL. 97

NO. 5

NOVEMBER 1962

331

PROBLEMS OF BLOOD PRESSURE IN CHILDHOOD

—Arthur J. Moss, M.D., Associate Professor of Pediatrics
(Cardiology), Department of Pediatrics, and Forrest H.
Adams, M.D., Professor of Pediatrics and Head Division
of Cardiology, Department of Pediatrics, both at the
University of California School of Medicine, Los Angeles.
Charles C. Thomas, Publisher, 301-327 East Lawrence
Avenue, Springfield, Illinois, 1962, 106 pages, $5.50.

This small volume presents much useful information
which is not elsewhere easily available in such succinct
form. Both methodology and interpretation receive excellent
discussion. The extensive tables contain valuable standards
for all ages of childhood and for variations in health and
disease and in the interpretation of these variations. The
format is clear and concise. This volume is a valuable
reference which should be available in every library devoted
to pediatrics.

Edward B. Shaw, M.D.

* * *

THE POSTTHROMBOPHLEBITIC SYNDROME— Roy

J. Popkin, M.D., F.A.C.A., Attending in Medicine, Cedars
of Lebanon Hospital; Chief (Emeritus), Peripheral Vas-
cular Disease Clinic, Cedars of Lebanon Hospital, Los An-
geles, Calif. Charles C. Thomas, Publisher, 301-327 East
Lawrence Avenue, Springfield, 111., 1962. 221 pages, $8.50.

This monograph by Dr. Roy J. Popkin on the postthrom-
bophlebitic syndrome deals with all aspects of this disease
entity, including diagnosis, acute and long term manage-
ment, complications and sequelae. It covers the industrial,
economic and social aspects of the disease. After a brief
historical introduction, the anatomy and physiology of the
lower extremities are carefully considered. The nature of
thrombosis, the effects of stasis and sludging of the blood,
and the pathogenesis of the postthrombophlebitic syndrome
are well summarized. The place of phlebography in the
diagnosis of the disease is emphasized. The conservative
management is well covered, including discussions on elas-
tic bandages, exercise, medications, treatment of local ulcers,
physiotherapy, the use of anticoagulant and fibrinolytic
agents. Unfortunately, the section on surgical manage-
ment of the disorder is sparsely documented, and one could
find little to recommend in the section on surgical treatment
of this disorder. Actually, a major arm of therapy in the
postthrombophlebitic syndrome centers around the surgical
aspects of the disease, and for one interested in therapy the
book is inadequate. There is considerably less information
in it, for example, than in one of the standard textbooks on
varicose veins, such as the recent excellent book by Dodd
and Cockett. The reviewer would feel that this book is a
worthwhile contribution to the understanding of the post-
thrombophlebitic syndrome, but would feel that there is
hardly sufficient new information in it to warrant use of
the book other than for a quick review. It cannot be recom-
mended for general purchase for either the internists’ or
surgeons’ library. It is suitable for a general medical library
in a hospital or university environment.

AN INTRODUCTION TO THE STUDY OF DISEASE
(formerly “An Introduction to Medical Science”) — Fifth
Edition, Thoroughly Revised, 174 Illustrations and 4 Col-
ored Plates — Williaan Boyd, M.D., Dipl. Psychiat., M.R.C.P.
(Edin.), Hon. F.R.C.P. (Edin.), F.R.C.P. (Lond.), F.R.C.S.
(Can.), F.R.S. (Can.), LL.D. (Sask.), (Queen’s), D.Sc.
(Man.), M.D. (Hon.) (Oslo), Professor Emeritus of Pa-
thology, The University of Toronto; Visiting Professor of
Pathology, The University of Alabama; Formerly Profes-
sor of Pathology, The University of Manitoba and the
University of British Columbia. Lea & Febiger, 600 Wash-
ington Square, Philadelphia 6, Pa., 1962. 478 pages, $7.50.

This is a masterful book intended for those beginning or
considering the study of medicine, medical technology, and
other paramedical disciplines. It is the fifth edition of
a book formerly entitled, An Introduction to Medical
Science, but the new edition has many rewritten chap-
ters. Among those are; “Derangements of Body Fuids,”
“Fungus Infection,” “Viruses and Rickettsia,” “Ionizing
Radiation,” “Hereditary Diseases,” “Immunity and Hyper-
sensitivity,” and “Care of the Patient.” All of the chapters
have been rewritten and revised and, as the author is justly
famous, place an emphasis on the relationship of symptoms
to lesions. The present book is not only a general introduc-
tion to the study of disease, but presents an overview of the
subject, so that one can grasp the present status of the total
subject, even though the survey must necessarily be brief
and undetailed. Actually it is far more difficult to present
an overview of the principles of disease rather than to pre-
sent details of the individual organs and systems and their
diseases, and the author succeeds admirably in presenting
this “airplane view of the subject.” As an aside, the author
gives a list of classical prefixes and suffixes which are help-
ful in understanding the medical terms. In addition, he gives
the classic derivation of many words, also of great interest
and help to the newcomer to the study of disease.

The organization of the book consists of fourteen intro-
ductory chapters on some general principles including an
excellent account of the healthy cell and of the importance
of the cell membrane, the nucleus, chromosomes, the mito-
chondria, nucleic acids, etc. There are then fifteen chapters
on the specific organs and their diseases, which combine a
concise description of the disease as well as a discussion of
normal anatomy and physiology. As might be expected in
a book of this sort, there is no discussion of moment regard-
ing treatment. One hundred and seventy-four figures illus-
trate the text and by and large, these are clear and informa-
tive. The index is complete, but there is no bibliography.

In general, the book is an excellent contribution to the
need of the intelligent layman and paramedical individual
for a comprehensive general account of the study of disease
and should reach a broad audience. The text is clear, inter-
estingly written and can be very highly recommended.

Maurice Sokolow, M.D.

332

CALIFORNIA MEDICINE

LOMOTIL

(brand of diphenoxylate hydrochloride with atropine sulfate)

ANTIDIARRHEAL
TABLETS and LIQUID

lowers motility / relieves cramping / controls diarrhea

Roentgenographic studies by Demeulenaere1 estab-
lished that a single dose of 10 mg. of Lomotil slowed
gastrointestinal transit within two hours and that
it maintained its decelerating activity for more
than six hours.

In diarrhea this lowered propulsion permits a
physiologic absorption of excess fluid, lessens
frequency and fluidity of stools and gives safe,
selective, symptomatic control of most diarrheas.
Concurrently, it conserves electrolytes an‘d controls
cramping.

Investigators have found the antidiarrheal action
of Lomotil not only “excellent”2 but “efficacious3
where other drugs have failed. . .

dosage: For adults the recommended initial dosage
is two tablets (2.5 mg. each) three or four times
daily, reduced to meet the requirements of each
patient as soon as the diarrhea is under control.
Maintenance dosage may be as low as two tablets
daily. For children daily dosages, in divided doses,
range from 3 mg. (Vz teaspoonful three times daily)
for infants 3 to 6 months to 10 mg. (1 teaspoonful

five times daily) for children 8 to 12 years. Lomotil
is supplied as unscored, uncoated white tablets of
2.5 mg. and as liquid containing 2.5 mg. in each
5 cc. A subtherapeutic amount of atropine sulfate
(0.025 mg.) is added to each tablet and each 5 cc.
of the liquid to discourage deliberate overdosage.
The recommended dosage schedules should not
be exceeded.

NOTE: Narcotic prescription is required in Cali-
fornia.

Descriptive literature and directions for use de-
tailed in Physicians’ Product Brochure No. 81
available from G. D. Searle & Co., P. O. Box 5110,
Chicago 80, Illinois.

1. Demeulenaere, L.: Action du R 1132 sur le transit gastrointestinal, Acta Gastroent.
Belg. 21.-674-680 (Sept.-Oct.) 1958.

2. Kasich, A M.: Treatment of Diorrhea in Irritable Colon, Including Preliminary Ob-
servations with o New Antidiarrheal Agent, Diphenoxylate Hydrochloride (Lomotil),
Amer. J. Gastroent. 35.46-49 (Jan.) 1961.

3. Weingarten, 8.. Weiss, J., and Simon, M.: A Clinical Evaluation of a New Anti-
diarrheal Agent, Amer. J. Gastroent. 35.628-633 (June) 1961.

e. d. SEARLE & CO.

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NOVEMBER 1962

A.M.A. Foundation Appeals
For Student Loan Funds

The American Medical Association’s new Educa-
tion and Research Foundation has issued an urgent
appeal for substantial additional funds to keep in
operation its new loan guarantee program for medi-
cal students, interns and residents.

The program, begun last February, already has
loaned more than $6,000,000 to more than 3,300
physicians-to-be. These are long-term loans, made
through a bank, with the A.M.A.-E.R.F. acting in
effect as co-signer. The bank provides $12.50 in loan
funds for each $1 posted in the loan guarantee fund
by the new foundation.

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CTALIFORNIA

SEEKS PHYSICIANS

for Psychiatric and General Medical
assignments in State facilities of the De-
partments of Mental Hygiene, Correc-
tions, Youth Authority.

Offering liberal salaries, a variety of
professional placement, and selection of
locale. No written examination. Inter-
views in San Francisco and Los Angeles
twice monthly.

Write for details to:

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801 Capitol Avenue,

Sacramento, California

Almost $700,000 in loan guarantee funds have
been posted by physicians and others. The fund is
now virtually exhausted and new requests for loans
are being received at the rate of 150 each week.
Loans have been made in 49 states, to students in 81
different medical schools, and to interns and resi-
dents in 320 different hospitals.

“We are almost swamped by the success of this
program,” declared George M. Fister, M.D., presi-
dent of the A.M.A.

“The immediate and widespread rush of loan
applications is a clear-cut indication of the need for
more funds on the part of most of the 55,000 young
men and women now in medical schools and serving
internships and residencies in hospitals,” Dr. Fister
said.

Dr. Fister hailed the new loan guarantee program
as an outstanding example of free enterprise meeting
the needs of a segment of society in the traditional
American manner.

“These young men and women don’t want gov-
ernment handouts. They want to pay their own
way, if they can just manage to find some means
of so doing. The loan guarantee program of the
A.M.A.-E.R.F. is an important part of helping the
future doctors to finance their own education and
training,” he said.

“I am confident that the additional funds needed
to keep this program an on-going, viable support of
medical education will be forthcoming,” Dr. Fister
said.

High Altitude Skiing
Hazardous for Some

High altitude skiing can be hazardous for certain
susceptible individuals, according to an editorial in
the September 29 Journal of the American Medical
Association.

Published reports of two skiers who developed a
potentially fatal lung condition while skiing at alti-
tudes of from 6,000 to 10,300 feet were cited in the
editorial.

The skiers, both physicians, aged 46 and 48, ex-
perienced difficulty in breathing, developed a cough
and turned blue from lack of oxygen, the editorial
said. Their condition was diagnosed as pulmonary
edema, a leakage of fluid into the air spaces and
tissues of the lungs, it said.

The 48-year-old physician was near death when
admitted to a hospital, the editorial said, but both
patients recovered rapidly with oxygen therapy and
bed rest.

The Journal also cited reports of persons who live
at high altitudes developing the same syndrome upon
returning from a short stay at sea level.

These studies suggest that the syndrome is due
to a transient constriction of the minute veins of the
lung, the editorial said. There also are indications
that susceptibility may be inherited, it said.

CALIFORNIA MEDICINE

A.M.A. Advises on Employment
Of Former Mental Patients

Most persons who have recovered from mental
illness can return to the same type of job held before,
the American Medical Association said recently.

“Successful psychiatric treatment results in im-
provement in joh performance, attendance, safety,
conduct, attitude, and insight,” a joint statement by
A.M.A.’s Council on Occupational Health and Coun-
cil on Mental Health said.

The performance of a recovered patient compares
favorably with that of employees in general, it said,
adding:

“If the individual can handle the job or can ad-
just to it in reasonable time, and if he has medical
approval to work, he should be given the same
consideration for employment as any other worker."

It is a “too common misconception that once a
person has had a mental illness he remains ill for
the rest of his life,” the A.M.A. statement said, and
the patient himself may share this pessimistic out-
look.

While impairment does greatly restrict employ-
ability of some chronic schizophrenic patients, it
said, “individuals with arrested schizophrenia and
unimpaired work habits usually can return success-
fully to work under proper supervision and with
acceptable job conditions.”

“Persons who have manic-depressive reactions ex-
perience relapses which may interrupt their work
but which do not necessarily render them unemploy-
able,” the statement said.

Neither should the mere diagnosis of mental illness
be used to deny employment, it was pointed out.

“Because of great variations in type and severity
of the illness, and because it often is impossible to
make an accurate psychiatric diagnosis until quite
some time after the symptoms appear, a diagnosis
of psychiatric illness is not, per se, sufficient ground
for denying employment or discharging an em-
ployee,” the statement said. “Indeed, many psy-
chiatric patients, including psychotics, make very
satisfactory employees.”

In conclusion, it said: “Successful employment of
individuals who are physically handicapped depends
upon proper placement and an understanding of the
problems of these individuals on the job. This ap-
plies equally to individuals who have recovered
from psychiatric illness.”

The statement, issued as a guide to physicians in
evaluating employability of former psychiatric pa-
tients. appeared in the September 22 Journal of the
American Medical Association. In was prepared by
a joint committee of the two American Medical As-
sociation councils consisting of L. E. Hinder, M.D..
Ann Arbor. Mich., chairman; R. T. Collins, M.D..
Rochester, N. Y. ; W. D. Ross, M.D., Cincinnati;

L. H. Bartemeier, M.D., Baltimore; E. S. Jones.

M. D., Hammond, Ind., and L. N. Hames, secretary.
Chicago.

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REFERENCES AND REVIEWS

(Continued on Page 33)

irradiation is the preferred form of therapy, either alone or
in combination with surgery. When last seen 60 per cent of
patients were apparently cured. Multiple courses of irradia-
tion, repeated surgery, or a combination of both were
required for 45 per cent.

an accuracy of 98.4 per cent with the latter. In the non-
pregnant group four incorrect results were obtained with
the PD test and one with the AZ test. No significant side
effects occurred in this group or in an additional series of
100 cases, all known to be pregnant. In the largest number
of cases a negative result becomes available within three
days after the last dose of the estrogen-progesterone com-
bination.

Detection of Coxsackie Virus Anticen in Urinary Cells
by Immunofluorescence — Y. Hinuma, T. Miyamoto, Y.
Murai, and N. Ishida. Lancet, 2:179 (July 28) 1962.

The complement method of fluorescent antibody technique
revealed Coxsackie B-5 virus antigen in exfoliated cells in
the urine of 6 to 12 patients with aseptic meningitis. The
diagnosis of Coxsackie B-5 virus infection was confirmed in
four of the six patients, by virus isolation or by demonstra-
tion of specific antibody rise, or both. Detection of virus
antigen in urinary cells by the immunofluorescence may
aid in rapid specific diagnosis of the virus infection.

A Novel Test for Pregnancy — R. X. Sands, J. Mayron,
and A. V. Pinski. New York J. Med., 62:2494 (Aug. 1)
1962.

In the experiments described the withdrawal bleeding
which follows the combined use of anhydrohydroxyprogeste-
rone, a progestational agent, and ethinyl estradiol, an
estrogen (Pro-Duosterone [PD]) was used in testing for the
presence of early pregnancy. The procedure is referrred to
as the PD pregnancy test. Of 122 women in whom the PD
and the AZ ( Aschheim-Zondek) tests (Frank-Berman modi-
fication) were performed, 66 were found to be pregnant and
56 nonpregnant. Among the 66 pregnant nine false results
were obtained with the AZ test and one with the PD test,

Response of Infants to Pertussis Vaccine at One Week
and to Poliomyelitis, Diphtheria, and Tetanus Vac-
cine at Six Months — N. R. Butler, B. D. R. Wilson, P. F.
Benson, J. A. Dudgeon, J. Llngar, and A. J. Beale. Lancet,
2:112 (July 21) 1962.

Infants were given pertussis vaccine either plain or ad-
sorbed onto aluminum phosphate in the first week of life.
The agglutinin response was superior with the absorbed
vaccine. The two vaccines gave equally good protection
against whooping cough in a follow-up study. The paper
contains a misprint, for among controls there were 14 cases
(not 24 as stated) among 24 home exposures. Children given
polio, diphtheria, and tetanus vaccine starting at six months
made a satisfactory response to all the components. This
schedule is immunologically sound but has the drawback of
employing two courses of vaccination.

❖ * ❖

Open Door — Ten Years’ Experience in Dingleton —
R. A. W. Ratcliff. Lancet, 2:188 (July 28) 1962.

Statistics of Dingleton, the only mental hospital in Scot-
land functioning entirely without locked wards, are com-
pared with those relating to Scottish mental hospitals in
general. Quantitative assessment is attempted of (1) risks
to the patient (death by suicide and accident), (2) possible
embarrassment to the community (escapes and police

arlidin

increases
blood flow
to the brain
in the
senility syndrome’
associated
with

cerebrovascular
insufficiency

charges against |>atients), and (3) possible gains to the
community I numbers of admissions, the proportions of
admissions which were voluntary, readmission, turnover, and
discharges in selected years between 1945 and 1959) . The
statistics strongly support the case for continuing open-door
administration in a 400-bed mental hospital situated in and
drawing its patients from an area of small towns and rural
districts.

* * *

Heart Sounds and Murmurs in 400 Normal Subjects —

H. N. Segall. Canad. Med. Assn. J. 87:377 (Aug. 25)

m2.

To define the range and the modal pattern of normal

I heart sounds and murmurs as heard at six “areas of auscul-

tation,” data collected on 400 subjects are analyzed. The
method of writing quantitative symbols to describe what is
heard while listening provides precise records. From data
on 100 young men, (aviation pilots) a modal pattern was
derived which serves as a standard normal pattern on a
heart-sound chart used in writing quantitative symbols for
heart sounds and murmurs. Data of the 100 pilots are com-
pared with those of 300 selected “normal” patients and of
4,889 persons in a mixed population of patients. The
graphic patterns of heart sounds and murmurs described by
quantitative symbols demonstrated the details of normal
range and modal pattern.

* # *

Significance of Skin and Serologic Tests in Diagnosis
of Pulmonary Residuals of Histoplasmosis — J. H.
Richert and C. C. Campbell, Amer. Rev. Resp. Dis.,
86:381 (Sept.) 1962.

In a review of 123 cases of pulmonary histoplasmosis
proved pathologically or culturally, it was found that 97
per cent of 117 patients who received histoplasmin skin

tests reacted positively. Only 48 per cent of the 73 patients
who were tested serologically reacted positively, and most
of the positives had low titers. The histoplasmin skin test is
valuable in excluding histoplasmosis hut the serologic tests
have little diagnostic significance in the inactive stage of
the disease.

* * *

Transmission of Retinoblastoma — R. C. Drews. Arch.
Ophthal. 68:329 (Sept.) 1962.

Of 13 siblings studied, three died of retinoblastoma. The
10 who were unaffected had 16 children, and of these three
had retinoblastoma.

* * *

Benign and Malicnant Oncocytoma — H. Hamperl. Can-
cer, 15:1019 (Sept.-Oct.) 1962.

The occurrence of oncocytes in normal organs is due to
a special degenerative metaplasia that does not prevent the
cells from dividing. Oncocytes may appear in neoplasms as
single cells, or they may form a more or less substantial
part of the tumor, or the tumor may be composed entirely
of the oncocytes. It is only in this latter instance that such
tumors should be called oncocytomas (benign or malignant) .
Examples of such tumors from various organs are given.

* * *

Direct Retrograde Femoral Aortography — J. A. Wald-
hausen and E. C. Klatte. New Eng. J. Med., 267:480
(Sept. 6) 1962.

A technique of abdominal aortography that is an exten-
sion of simple femoral arteriography is described. It clearly
outlines disease of the abdominal aorta and some of its
branches, including the renal and iliac vessels. Demon-
stration of the ileofemoral tree of the opposite pulseless
extremity may be easily performed. This method has proved
to be safe and reliable on approximately 100 patients.

Inadequate cerebral blood flow — often due to cerebral arteriosclerosis — may
result in the "senility syndrome” with its pattern of mental confusion, mem-
ory lapses, depression, fatigue, apathy and behavior problems. 1-3

43% increase in cerebral blood flow with Arlidin4

In patients with cerebrovascular insufficiency, Eisenberg^ measured a 43 per-
cent increase in blood flow in the brain following administration of Arlidin
orally for more than two weeks beginning with a dosage of 12 mg. t.i.d. and
increasing to 18 mg. t.i.d. There was a decrease in cerebral vascular resist-
ance in mdst instances.

Winsor and associates3 found Arlidin "of particular value clinically in reliev-
ing some of the symptoms of cerebral vascular insufficiency (vertigo, light-
headedness, mental confusion, diplopia).”

arlidin

(BRAND OF NYLIDRIN HCI NND)

references: 1. Madow, L.: Penn. M. J. 62:861, June 1959. 2. Stieglitz, E. J.: Geriatric Medicine,
ed. 2, Philadelphia, Saunders, 1949 p. 274. 3. Winsor, T., et al.; Amer. J. Med. Sciences 239:594,
May 1960. 4. Eisenberg, S.: ibid, July 1960.

NOTE — before prescribing ARLIDIN the physician should be thoroughly familiar with
general directions for its use, indications, dosage, possible side effects and contraindi-
cations, etc. Write for complete detailed literature.

u. s. vitamin & pharmaceutical corporation

Arlington-Funk Labs., division • 800 Second Avenue, New York 17, N. Y.

A.M.A. Clarifies Stand on
Drug Addict Therapy

The American Medical Association said recently
it is not opposed to experimental ambulatory, or out-
patient, clinics for the rehabilitation of narcotic
addicts.

The A.M.A. does oppose out-patient clinics in
which addicts would be given drugs primarily for
the maintenance of addiction. It does not oppose
out-patient clinics that would assist in the care and
rehabilitation of addicts.

The A.M.A.’s position on out-patient clinics for
addicts has been misinterpreted in two recent maga-
zine articles, Dr. Dale C. Cameron, Washington,
D. C.. chairman of the A.M.A. Committee on Nar-
cotic Addiction, said.

The development of an experimental facility for
the out-patient treatment of drug addicts was en-

dorsed by the A.M.A. in 1959 and re-endorsed in a
joint statement with the National Research Council
last May, Dr. Cameron said.

To date, no properly controlled experimental fa-
cility for the treatment of narcotic addicts has been
established, he said.

For this reason, the A.M.A.-N.R.C. statement,
referring to general non-experimental treatment serv-
ices, said “on the basis of current knowledge”
ambulatory clinics were opposed, he said.

“Certainly, the report does not preclude future
recommendations based on new knowledge gained
through research,” he said.

Since some out-patient clinic plans call for drug
maintenance as in Great Britain, Dr. Cameron cited
the 1959 statement which emphasized that “no ac-
ceptable evidence whatsoever points to the indis-
criminate distribution of narcotic drugs as a method
of handling the problem of addiction.”

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Room 109, lOIVi East Huntington Drive, Arcadia Telephone MUrray 1-5077

Mailing Address: P. O. Box 543, Arcadia

CALIFORNIA MEDICINE

Injuries Are Main Reason Children Lose Eye

Loss of an eye in childhood is caused by an injury
in more than half the cases, according to an article
in the September 15 journal of the American Med-
ical Association.

In a study of 402 children under 15 years of age
who had an eye removed, 222 (55 per cent) resulted
from an injury, Drs. Leonard Apt and L. K. Sarin,
Philadelphia ophtalmologists, reported.

The greatest number of these cases occurred be-
tween the ages of five and eight, they said. Eighty-
one per cent occurred after the age of three, they
said. Agents causing the injuries included an arrow,
knife, pen, bullet, dynamite, pieces of glass and stone,
steel, screw driver, nail, belt, fist, rope, rubber band,
and toy airplane, they said.

“It is significant to observe that a sharp increase
in the number of cases was found at the age when
the child begins to attend school,” the two physicians
said. “The fact that over one-third of the total num-
ber . . . resulting from trauma occur in the first
phase of primary school underlines the responsibility
which must be met by both parent and teacher dur-
ing this period of transition in the life and activities
of the child.”

Safety education aimed at parents and children
and legislative control of dangerous items such as
fireworks and BB guns already has had an effect
on the occurrence of blindness from injury, which
is decreasing markedly, they said.

In one community alerted to the danger of eye
injuries from toys during the Christmas season,
they said, the number of eye losses was reduced by
more than two-thirds during that period. Newspaper
stories, radio announcements, discussion at Parent-
Teacher Association meetings, and school demon-
strations of potentially dangerous objects were used
in this safety campaign, they said.

“Frequent campaigns of safety education directed
at parents, teachers, baby sitters, and toy manu-
facturers are needed to reduce the number of eye
injuries and thus the loss of children’s eyes, ’ a
Journal editorial said.

African Tumor Compares with
Leukemia Elsewhere

A commonly occurring tumor in African children
may be a different manifestation of the same disease
process that causes a common form of acute leuke-
mia in children in the United States, Dr. Gilbert
Dalldorf, Sloan-Kettering Institute for Cancer Re-
search, New York City, said recently.

“In both diseases the tumor cell is the same,” he
said in the September 22 journal of the American
Medical Association.

Although the symptoms of the diseases are differ-
ent, Dr. Dalldorf said, both run a rapid, devastating
course and both respond similarly to radiation ther-
apy and to various drugs.

Both diseases represent roughly 40 per cent of all

malignant tumors in children in each country, he
said, and in both countries boys are more frequently
affected than girls.

The disease found in Africa is termed malignant
lymphoma since the tumor is made up of lymphoid
tissue, tissue which acts as a filter for the watery
fluid of the body known as lymph.

Lymphomas in North America and in most of the
world are often associated with lymphoblastic leu-
kemia, Dr. Dalldorf said. This type of leukemia, or
cancer of blood-forming tissues, is characterized by
rapid growth and overactivity of lymphoid tissue.

This type of leukemia is the most common malig-
nancy of children in America and the least common
in East Africa, Dr. Dalldorf said.

In a review of 130 lymphomas in children under
15 years of age in Kenya, he said, only 2 per cent
were found to be associated with leukemia. In the
Llnited States, he said, all but 5 per cent of the lym-
phomas in children are associated with leukemia.

If both diseases are different expressions of child-
hood lymphoma, Dr. Dalldorf said, the agents
responsible must be assumed to exist in both conti-
nents, possibly in somewhat different form or subject
to host or environmental factors that modify their
characteristics.

“It would seem as important to determine, if pos-
sible, why lymphomas in America are usually leu-
kemic as to determine why those in Africa are
tumorous and not leukemic,” he said.

Management of Common Fractures & Dislocations One Week, Dec. 3
Board of Infernal Medicine Review, Part II One Week, Dec. 3
Breast & Thyroid Surgery One Week, Dec. 3

Gallbladder Surgery Three Days, Mar. 11, 1963

Surgery of Hernia Three Days, Mar. 14, 1963

Clinical Courses in Fractures, Dermatology, Pediatrics,

Radiology By Appointment

Information concerning numerous other continuation courses
available upon request.

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CONTINUING EDUCATION COURSES
STARTING DATES— 1962-1963

Anesthesia — Inhalation, Endotracheal, Regional By Appointment

Surgical Technic Two Weeks, Feb. 18, 1963

Surgery of Colon and Rectum One Week, Nov. 26

Vaginal Approach to Pelvic Surgery One Week, Dec. 17

Gynecology, Office & Operative Two Weeks, April 1, 1963

Obstetrics, General & Surgical Two Weeks, Nov. 26, Mar. 11, 1963

Proctoscopy & Sigmoidoscopy One Week, Dec. 17, Jan. 28, 1963

Varicose Veins One Week, Dec. 17, Jan. 28, 1963

General Surgery One Week, Feb. 25, 1963

Advances in Surgery One Week, Dec. 10

Board of Surgery Review, Part II Two Weeks, Nov. 26, Mar. 4, 1963
Basic Internal Medicine Two Weeks, Mar. 4, 1963

Advertising • NOVEMBER 1962

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Each tablespoonful (15 cc.) contains theophylline 80 mg. (equivalent to 100 mg. amino-
phylline) in a hydroalcoholic vehicle (alcohol 20%).

Acute Attacks: single dose of 75 cc. for adults; 0.5 cc. per lb. of body weight
for children.

24 Hour Control: for‘adults 45 cc. doses before breakfast, at 3 P.M., and before

retiring; after two days, 30 cc. doses,
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(Gastric distress rarely encountered.)

References: (1) Kessler, F.: Connecticut S.M.J. 21: 205
(March) 1957. (2) Burbank, B.; Schluger, J., and McGinn,
J.: Am. J. Med. Sci. 234:28 (July) 1957. (3) Spielman, A.D..
Ann. Allergy 15: 270 (June) 1957. (4) Greenbaum, J.: Ann.
Allergy /6:312 (May-June) 1958. (5) Kessler, F.: Medical
Times 57:1298 (Oct.) 1959. (6) Bickerman, H.A., and Barach,

Children, first 6 doses 0.3 cc.— then 0.2 cc.

A. L., in Modell, W.: Drugs of Choice 1960-1961, St. Louis,
The C. V. Mosby Company, 1960, p. 516. (7) Wilhelm, R. E.
in Conn., H. F.: Current Therapy— 1961, Philadelphia, W. B.
Saunders Company, p. 417. (8) Schluger, J. McGinn, J. T.,
and Hennessy, D. J.: Am. J. Med. Sci. 233: 296, 1957.

Detroit 11, Michigan

CALIFORNIA MEDICINE

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Codeine Phosphate* 15 mg.

‘Sudafed’® brand Pseudoephedrine Hydrochloride 20 mg.

‘Perazil’® brand Chlorcyclizine Hydrochloride 15 mg.

Acetophenetidin 150 mg.

Aspirin (Acetylsal icyl ic Acid) 200 mg.

Caffeine 30 mg.

A Iso available
without codeine as @

‘EMPRAZIL’

TABLETS

^Warning— may be habit forming.
Complete literature available on request.

BURROUGHS WELLCOME & CO. (U.S.A.) INC .g TLCKAHOE, N.Y.

Advertising • NOVEMBER 1962

Nationwide Chain of Ear Banks
Seeks Inner Ear Bones

A nationwide drive for bequests of the temporal
or inner ear bones upon death is under way to aid
researchers in the battle against deafness.

The campaign was launched by The Temporal
Bone Banks Center in Chicago, recently established
as coordinating agency for a chain of 22 ear banks.

The story of the ear banks is told in the October
Today’s Health magazine, published by the American
Medical Association.

The ear banks are primarily interested in obtain-
ing the bones of persons afflicted with disorders of
hearing and equilibrium. From these bones and the

Your public relations problem lias been
our prime consideration in collection
procedures during two generations of
ethical service to the Medical Profession.

THE DOCTORS BUSINESS BUREAU

Since 1916

FOUR OFFICES FOR YOUR CONVENIENCE:

821 Market St., San Francisco 3 GArfield 1-0460

Latham Square Bldg., Oakland 12 GLencourt 1-8731

617 S. Olive St., Los Angeles 14 MAdison 7-1252

19 Pine Ave., Long Beach HEmlock 5-6315

individual’s medical history, scientists can deter-
mine the pathological conditions that accompany
various types of deafness and evaluate the effects of
previous treatment.

“There is much yet to be learned about deafness,”
according to Dr. John R. Lindsay, director of the
Chicago center, “not only because there are many
types of deafness but because we do not yet know
enough about what goes on in the inner ear or about
the relationship of the inner ear to the brain.”

The donated bones of persons with normal hear-
ing are also sought by the ear banks to aid in the
training of ear surgeons. Surgery on the ear requires
extraordinary skill which can be acquired only by
surgical training on human ear structures.

Anyone interested in willing his ear bones to
science may obtain legal forms for making such
bequests from The Temporal Bone Banks Center,
Box 146, Faculty Exchange, University of Chicago,
Chicago 37, 111.

Cytotoxic Effect of Heterologous Lymphoid Cells —

A. E. Stuart. Lancet, 2:180 (July 28) 1962.

Heterologous lymphoid cells had a typical cytopathic
effect on the monolayers of HeLa cells in tissue culture.
Living cells were necessary and immunized cells accelerated
the destruction of the monolayers. Heterologous lymphoid
cells given to mice with an ascites tumor produced tem-
porary amelioration, but subsequently the tumor progressed
in all the treated animals.

When treatment for

is indicated

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Each yellow tablet contains:

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Methyl Testosterone . .

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Thyroid Ext. (1/6 gr.) .

. . .10 mg.

Thyroid Ext. (1/2 gr.) .

. . .30 mg.

Glutamic Acid

. . .50 mg.

Glutamic Acid

Thiamine HCI

. . . 10 mg.

Thiamine HCI

. . . 10 mg.

Indications: Impotence in male.

Average Dose : One tablet three times daily.

Available : Bottles of 100 and 500 at your pharmacy.

Caution : Not to be used when testosterone is contra-indicated.

Federal law prohibits dispensing without prescription.

1. Methyltestorone-Thyroid in Treating Impotence, A. S. Titeff, General
Practice, Vol. 26, A ro. 2, Feb., 1962, pp. 6-8.

2. Thy raid.- Androgen Relations, L,. Ilellman, et a).. The Jrl. of Clin. Endo-
crinology and Metabolism, August 1969

Write for samples and literature .. .

(BRoWjyfc THE BROWN PHARMACEUTICAL COMPANY

2500 West Sixth Street, Los Angeles 57, California

CALIFORNIA MEDICINE

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Physician’s Health Record
On Par With Businessman

The average physician’s health record is generally
on a level with that of the businessman, a study
indicated recently.

The conclusion was based on a comparison of
periodic health examinations given a professional
group of 68 persons, 61 physicians and 7 dentists,
and identical examinations given 500 business ex-
ecutives.

Both groups were ostensibly well and middle-aged
although the executives were somewhat older.

The study revealed no significant difference be-
tween the two groups in either incidence of major,
unknown diseases detected by the examinations or
per cent of individuals in which these diseases were
found, Drs. John C. Sharpe and William W. Smith,
Beverly Hills, Calif., reported in the October 20
Journal of the American Medical Association.

Previously unsuspected and significant diseases
were found in 45.5 per cent of the physician group
and in 43.7 per cent of the executive group, the
researchers said. Of all diseases found in the physi-
cian group, 14.6 per cent were significant compared
with 13.4 per cent in the executive group, they said.

The similarity of these figures is understandable
since most of the significant diseases had produced
no apparent symptoms and therefore were not recog-
nized by either physician or layman, they said.

Diseases were considered significant if they could
interfere with the individual’s health or shorten his
life, they said.

“Not only did the physicians have an equal
amount of significant, unknown disease, but many
more physicians than executives needed treatment,
not only for these new conditions, but also for those
known to be present beforehand,” the researchers
said.

Seventy-two per cent of the significant unknown
diseases found in the physicians required treatment
compared with 47.7 per cent of these diseases found
in the executives, the study showed.

Comparison of the two groups also showed a
slightly higher incidence of heart disease and peptic
ulcer among the physicians. However, the research-
ers said, there was no conclusive proof that physi-
cians had any occupational disease.

Re-examinations revealed a slightly higher in-
cidence of newly acquired disease among the physi-
cians than the executives, the study showed.

The Journal report also pointed out that one-third
of all important new diseases found among physi-
cians were detected by x-ray examination.

The researchers concluded: “In an effort to detect
early, unsuspected, and often major disease, there
is no sound reason why a physician should not have
a complete and periodic physical, laboratory, and
x-ray examination and thereby apply this knowl-
edge to the preservation of his own health.”

CALIFORNIA MEDICINE

night, the arthritic wakes up

comfortable

Morning stiffness may be reduced
or even eliminated as a result
of therapy with the only steroid in
long-acting form. And the slow,
steady release of steroid
makes it possible in some cases
to reduce the frequency of
administration and/or the total
daily steroid dosage.

Reminder advertisement.
Please see package insert for
detailed product information.

Medrol

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Each hard-filled capsule contains Medrol
(methylprednisolone) 4 mg. Also available
in 2 mg. soft elastic capsules.

Supplied in bottles of 30 and 100.

Upjohn

The Upjohn Company, Kalamazoo, Michigan

Discuss Medical Aspects
Of Steam Baths in J.A.M.A.

Steam rooms and Sauna baths appear to have
no beneficial effect on health in the opinion of two
consultants to the Journal of the American Medical
Association.

Writing on steam rooms in the question-and-
answer section of the October 20 Journal. Dr. David
I. Abramson. Chicago, said there are very limited
indications for, and many indications against, the
use of the steam room.

Generally in such an environment, he said, the
temperature varies between 110 and 170 degrees
Fahrenheit and the humidity is very high.

Your public relations problem has been
our prime consideration in collection
procedures during two generations of
ethical service to the Medical Profession.

THE DOCTORS BUSINESS BUREAU

Since 1916

FOUR OFFICES FOR YOUR CONVENIENCE:

821 Market St., San Francisco 3 GArfield 1-0460

Latham Square Bldg., Oakland 12 GLencourt 1-8731

617 S. Olive St., Los Angeles 14 MAdison 7-1252

19 Pine Ave., Long Beach HEmlock 5-6315

There appears to be no beneficial physical re-
sponse to exposure to a steam room that cannot
be accomplished by much less “heroic” means, he
said.

The steam room is definitely unwise for those with
any serious organic disability, such as generalized
hardening of the arteries, heart disorders, or an
overactive thyroid, he said. In addition, he said, the
high humidity would probably place an excessive
load upon the patient with even mild or moderate
disability of the heart and lungs.

Discussing Sauna baths, Dr. Kaare Rodahl,
Philadelphia, said:

“Although it may be difficult to demonstrate any
objective beneficial effect on health and physical
performance capacity, the Sauna is generally con-
sidered to contribute to a feeling of well-being.”

The Sauna is a hot steam bath taken in an en-
closed room heated by a stove on which water is
sprinkled at intervals. It has been used in Scan-
dinavia, notably in Finland, for centuries, Dr.
Rodahl said.

The effects on the heart and circulatory system
are essentially the same as those resulting from
exposure to heat, he said.

“It is conceivable that some harm could result
in older individuals unless care is taken to increase
the exposure gradually,” he added.

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Room 109, lOIVi East Huntington Drive, Arcadia Telephone MUrray 1-5077

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_____

CALIFORNIA MEDICINE

RELIEVE THE COLD
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WITH NEW

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ANTITUSSIVE. DECONGESTANT- ANALGESIC

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‘Sudafed’® brand Pseudoephedrine Hydrochloride 20 mg.

'Perazil'® brand Chlorcyclizine Hydrochloride 15 mg.

Acetophenetidin 150 mg.

Aspirin (Acetylsal icyl ic Acid) 200 mg.

Caffeine 30 mg.

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"•Warning -may be habit forming.
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BURROUGHS WELLCOME & CO. (U.S.A.) INC TUCKAHOE, N. 1

Advertising •

DECEMBER 1962

for your young patient with

• Emotional Problems

• Learning Difficulties

KINDERGARTEN THROUGH HIGH SCHOOL

DEVEREUX SCHOOLS IN CALIFORNIA

ROBERT G. FERGUSON. Ed.D., Director
KENNETH L. GREVATT, M.D., Medical Director
RICHARD H. LAMBERT, M.D., Psychiatric Director

You are invited to write
for our recent brochure.

KEITH A. SEATON, Registrar
Box 1079, Santa Barbara

SCHOOLS
COMMUNITIES
CAMPS
TRAINING
RESEARCH

HALF A CENTURY OF SERVICE TO CHILDREN

HELENA T. DEVEREUX EDWARD L. FRENCH, Ph.D.
Founder and Consultant President and Director

Boom in Medical Research
Neglects Major Aspect

Despite vastly expanded research, an important
approach to investigative medicine is being ne-
glected, according to an article in the October 13
Journal of the American Medical Association.

The rise of “research factories” is bringing about
the decline of the “clinical tradition,” Dr. Jurgen
Ruesch, professor of psychiatry, University of Cali-
fornia School of Medicine, San Francisco, wrote in
the Journal.

The clinical tradition implies bedside observation
and any kind of observation that deals with living
creatures, he explained. It employs only simple in-
struments, abstains from the elaborate control de-
vices used in experimental laboratory research, and
focuses on naturally existing conditions, he said.
The vast majority of effective surgical, medical,
and psychiatric treatment methods have been de-
veloped by individuals or small groups, he main-
tained.

With the advance of technology, however, em-
phasis in medicine swung away from clinical ob-
servation and measurement toward experimentation.
Dr. Ruesch pointed out.

Experimental, or laboratory, research relies upon
careful design, well-stated hypotheses, sophisticated
theories, control of as many variables as possible,
and precise measurement, he said. Measurement may
entail expensive equipment, he said, and experi-
ments may require a large personnel.

“As the numbers of people and machines used in
research increase, a human organization has to be
built to administer, supply, and maintain them.”
he said. “The result is the emergence of research
factories — the laboratories of the pharmaceutical
industry, research bodies of the government, and
research institutes in the universities.”

The invasion of “big science” into universities,
he continued, is diverting them from their primary
purpose by converting university professors into
administrators, housekeepers, and publicists.

A recent survey showed some schools are spend-
ing more than five times as much for research as
they are for undergraduate medical education, and
in some teaching departments the full-time research
workers outnumber full-time faculty members by
more than 10 to 1, he said.

At the same time, he said, the creation and
growth of research centers and institutes are ab-
sorbing available scientists and emptying univer-
sities of capable men.

The 20-fold increase of funds for medical re-
search in the last 15 years and the emphasis on
medical science have introduced new organizational
forms and attracted a new type of person into
medicine. Dr. Ruesch said.

Administration, research, and practice have be-
come separate disciplines, he said, the result being
(Continued on Page 3S)

THE

DEVEREUX

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CALIFORNIA MEDICINE

two coughs get?

Up to 8 hours with ULO*

Non-narcotic ULO puts a long, soothing pause be-
tween acute cough spasms. A teaspoonful usually
carries the patient comfortably through the night.

■ Suppresses acute cough longer than narcotics ... spares
your patient narcotic after effects. ■ Produces neither respir-
atory depression nor somnolence. Daytime doses will not dull
your patient. ■ Non-habituating. Patient does not develop a
tolerance. No constipation or taxation ... no gastric irritation
...no effect on intestinal motility. ■ Compatible with most
other medications.

RIKER LABORATORIES, INC., Northridge, California

Caution: Federal law prohibits dispensing without prescription.
For full product information, see Physicians’ Brochure accom-1
panying each package.

*Chlophedianol Hydrochloride

Fecal pH in
Constipation?

A stool pH of 6 or 5 usually indicates a
normal lactobacillus flora and a pH of 7
to 9 is abnormal, indicating a deficiency
of lactobacillus — the correlation being
about 94%.'

Marked to extreme deficiency of the lac-
tobacillus colonic flora responds well to
MALTSUPEX® which acts as a culture
medium to stimulate their rapid growth.1
Chronically constipated patients on a
MALTSUPEX regimen were greatly re-
lieved of their constipation and passed
soft, easily evacuated stools, all patients
having a fecal pH between 5 and 6. 2

pH FECAL pH IN CONSTIPATION2

7.5

...

•

6.5

•

. . .

5.5

* * *

Initial

1st Wk.

2nd Wk.

Twenty patients on MALTSUPEX® therapy for
three weeks (each dot^l patient).

“As the lactobacillus flora is gradually re-
stored to normal abundance, . . . bowel
movements become regular and of natural
consistency. The fecal pH declines from
9 or 7 to a normal 6 or 5.”’

"Stools become soft in all patients. . . ,”3
MALTSUPEX is a dependable prepara-
tion.4 Safe for infants,5 effective in old-
sters3—safe and effective in all consti-
pation.

Dosage, Description and Supply: Adults -
2 tablespoonfuls twice a day, reduced as
indicated. Infants-Vi to Vz adult dosage.
MALTSUPEX is a nutritive food concen-
trate derived from the natural enzymatic
digestion of barley. It is available as liquid
or quick-dissolving powder in 8 and 16
ounce jars.

References: 1. Raddin, J. B., and Dowell, L. B.
Amer. J. Gastroent. 37: 24-40 (January) 1962. 2
Calloway, N. O. : Paper to be published. 3. Hoot
nick, H. L.: J. Amer. Geriat. Soc. 4:1021-1030 (Oc
tober) 1956. 4. Bruce, J. W.: Pediat. Clin. N. Amer
8:163-165 (February) 1961. 5. Reichert, J. L. : Pe
diat. Clin. N. Amer. 2:527-538 (May) 1955.

Borcherdt Company,

217 N. Wolcott Avenue, Chicago 12, III.

New Oral Contraceptive

A new approach to birth control by oral adminis-
tration of hormones was presented Sunday, October
7, at the tenth annual meeting of the Pacific Coast
Fertility Society.

Called “sequential therapy,” the new system pro-
vides for administration of an estrogen, followed by
a combination of the estrogen and a new progesta-
tional agent, chlormadinone.

Starting on the fifth day of the female cycle, a
fifteen-day course of the estrogen is given. The
change to the combination is made on the twentieth
day and continues for five days. Withdrawal of the
drugs on the twenty-fifth day allows the cycle to
begin again, most commonly within the next two to
four days.

The new method differs in two respects from
conventional fertility-control systems: 1. The proges-
tational agent is given for only five days instead of
20; 2. the effects more closely duplicate the normal
conditions of the female cycle.

Chlormadinone is one of the most potent synthetic
progestational agents yet discovered.

The estrogen used in the clinical trial studies was
mestranol. Other estrogens also are under investiga-
tion as possibilities for the sequential therapy.

The report on the estrogen-chlormadinone method
was presented by Joseph W. Goldzieher, M.D., of
the Southwest Foundation for Research and Educa-
tion; J. Martinez Manoutou, M.D., and Harry W.
Rudel, M.D., of the Syntex Laboratories; and J. M.
Maas, M.D., of the Lilly Research Laboratories.

(Continued on Page 42)

Boom in Medical Research
Neglects Major Aspect

(Continued from Page 26)

that “we may well breed superb technicians, prac-
titioners, or organizational specialists but not medi-
cal leaders who know where the relevant problems
are and what to do about them.”

Decisions have moved out of the hands of subject
matter-oriented professionals into the hands of or-
ganization men; and these in turn must trust the
newly arisen technical advisors and researchers who
know little about medical practice or treatment, he
said.

“Materialism and overorganization are about to
kill the art of healing,” Dr. Ruesch concluded.

“Mediocre research and the concomitant neglect
of clinical training . . . have put the population in
double jeopardy.

“Scientific knowledge and clinical skill stimulate
each other, and unless both are maintained at a
high level of competence, progress in medicine may
be lagging.

“The progress of medicine depends as much on
the physicians who adapt the findings of medical
science as on the scientists who engage in research.
Both groups should be equally supported, rewarded,
and honored.”

CALIFORNIA MEDICINE

who

coughed?

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provides fast and
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relieves cough in 15-20 minutes •
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Dihydrocodeinone Bitartrate 5 mg.

(Warning: May be habit-forming)

Homatropine Methylbromide ... 1.5 mg.

Pyrilamine Maleate 12.5 mg.

Phenylephrine Hydrochloride 10 mg.

Ammonium Chloride 60 mg.

Sodium Citrate , 85 mg.

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Literature on request

ENDO LABORATORIES
Richmond Hill 18, New York

f /r

Hormone Relieves Infant Spasms

Hormone therapy reduced the frequency of seiz-
ures in 52 per cent of 21 children suffering a type of
epilepsy associated with physical and mental retarda-
tion, medical researchers reported recently.

The patients were given corticotropin, cortisone,
or both, J. Gordon Millichap, M.D., and Reginald G.
Bickford, M.B., Mayo Clinic, Rochester, Minn., said
in the November 3 Journal of the American Medical
Association.

Corticotropin, secreted by the pituitary gland,
stimulates the adrenal cortex, or outer part of the
adrenal gland, to produce cortisone.

At the time treatment was begun, the patients
ranged in age from one-half month to five years, the
researchers said. Fourteen were mentally retarded,
they said.

Fifteen of the children were treated with corti-
cotropin alone, two with cortisone alone and four
with both, they said. Seizures were reduced in fre-
quency in 11 of the 21, they said.

The study showed that the response of those who
received corticotropin was related significantly to
the age of the patient at the time treatment began.

In the 19 who received corticotropin, the physi-
cians said, seizures were controlled in 8 of 10
infants less than 1 year of age but only in 2 of 9
children over 1 year of age.

The beneficial effects of hormone therapy appear

to be “real” because of a relatively rapid response
and because previously administered anticonvulsant
drugs were ineffective, they said.

No significant or permanent improvement in the
level of intelligence was associated with the treat-
ment, they said.

The mechanism of the anticonvulsant action of
corticotropin is unknown, the physicians pointed
out. However, they said, it is possible that the basic
cause of the seizure disorder is a biochemical ab-
normality of genetic or acquired origin and a fail-
ure of certain enzymes to mature.

Control of the spasms by corticotropin might be
due to the stimulating effect on the biochemical ma-
turation of the brain and on the development of en-
zyme systems that inhibit the seizures, they said.

New Oral Contraceptive

(Continued from Page 38)

The clinicians said that chlormadinone shows a
marked and selective progestational effect on the
endometrium. It has neither estrogenic nor andro-
genic properties. In fact, it is an estrogen antagonist.
They found the drug to be well tolerated.

Chemically, chlormadinone is 6-chloro-17a-hydrox-
ypregna-4, 6-diene-3, 20-dione acetate.

Spokesmen emphasized that chlormadinone is still
under clinical investigation and not ready for gen-
eral use.

ARLIDIN IMPROVES HEARING1
ARLIDIN IMPROVES HEARING2
ARLIDIN IMPROVES HEARING3
ARLIDIN IMPROVES HEARING4

Arlidin is available in 6 mg. scored tablets,
and 5 mg. per cc. parenteral solution.

See PDR for packaging.
Protected by U.S. Patent Numbers: 2,661,372 and 2,661,373.

Arlidin “appears to be one of
the most satisfactory
[vasodilators], having the
advantages of minimal side effects,
being well tolerated and
possessing a sustained action”
in improving circulation
of the inner ear.

Seymour. J. C.: Laryngology &

Otology 74:133, 1960.

Turncoat Antibody Found
In Muscular Disorder

Man’s natural immunity mechanism, his ability
to produce antibodies to counteract invading germs,
is being investigated as a possible cause of a muscu-
lar disorder.

Autoantibodies, substances which are originally
manufactured by the body for protection but turn
against their host, have been found to be associated
with myasthenia gravis, or fatigue of the muscular
system, four researchers at the University of Buffalo
School of Medicine, Buffalo, N. Y., reported in the
October 6 Journal of the American Medical Asso-
ciation.

The cause of myasthenia is not known, but it is
believed to result from a functional abnormality in
the connection between nerves and muscles.

Previous investigators had found a factor with
specific affinities for skeletal muscle in the blood of
patients with the disease, according to the Journal
article.

The Buffalo workers — Ernest H. Buetner, Ph.D.,
Ernest Witebsky, M.D., Dieter Ricken, M.D., and
Richard H. Adler, M.D. — said they found additional
evidence that the factor was an antibody and estab-
lished that it was an autoantibody.

There are actually two autoantibodies that seem
to come into play, the authors said.

One antibody acts upon skeletal and heart muscle,

they said, while the second type acts only on skeletal
muscle. Earlier investigators apparently found only
the latter type, they said. Final proof of the exist-
ence of these two antibodies depends on further ex-
tensive experiments, they pointed out.

A small but increasing number of autoantibodies
with an affinity for certain organs are known to oc-
cur in association with certain diseases, the authors
said. Autoantibodies to heart muscle have been
found in cases of rheumatic fever, they said.

Evidence of the presence of antibody was drawn
from a comparison of 10 patients with myasthenia
and 32 patients with other muscular and non-muscu-
lar disorders, the researchers said. Among the 10
myasthenia patients, tests for antibody against skele-
tal muscle were strongly positive in 2, weakly posi-
tive in 3, doubtful in 8 and negative in 2, they said.
Among the other 32, they said, no tests were posi-
tive, 3 were doubtful and 29 were negative.

It was established by several techniques that both
types of antibodies were directed against the pa-
tient’s own tissues, they said. In one technique, a
blood sample from a patient with myasthenia re-
acted to a biopsy specimen from her own shoulder
muscle in the same way it reacted to other human
and monkey muscle specimens, they said.

“The mere demonstration of circulating auto-
antibodies in spite of exquisite specificity has never
(Continued on Page 46)

vascular insufficiency
of the labyrinth is an important
etiologic factor in sudden
perceptive deafness . . .
“vasodilators [Arlidin] are
of considerable value.”

Wilmot, T. J. and Seymour, J. C.:
Lancet 1:1098, 1960.

early cases of sudden
perceptive deafness should be treated
by immediate stellate block
"supplemented by the most effective
vasodilator drug [Arlidin] . . .
energetic measures to
retain blood supply to the inner
ear are imperative.”

Wilmot, T. J.: J. Laryngology &

Otology 73:466, 1959.

in impaired hearing,
tinnitus, vertigo . . .

when due to ischemia of the inner ear . . .

brand of nylidrin hydrochloride N.F.

Clinical benefit in approximately 50% of cases
of recent onset hearing loss treated with
adequate vasodilator and other supportive
therapy is also reported by Sheehy.

Sheehy, J. L.: Laryngoscope 70:885, 1960.

u. s. vitamin & pharmaceutical corporation

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Usual adult dose: 1 tablet t.i.d.
Before prescribing, consult
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Fungus Disease Found
Often in Eastern U.S.

A fungus disease, histoplasmosis, is probably as
prevalent in some of the Middle Atlantic states as
in any other part of the country, two researchers
said in the October 27 Journal of the American
Medical Association.

Of 1,924 elementary school children in Frederick
County, Md., who were tested to find out whether
they had been exposed to the disease-causing fungus,
histoplasma capsulatum, 35 per cent had a positive
reaction, Henry V. Chase, M.D., Frederick, Md.,
and Charlotte C. Campbell, B.S., Washington, D. C.,
reported.

Positive responses occurred in 26 per cent of 917
second graders and in 42 per cent of 1,000 sixth
graders, they said.

These figures are comparable to those obtained
in studies of similar age groups in some areas of
the Ohio and Mississippi River valleys where his-
toplasmosis has long been known to be highly
prevalent, the researchers said.

It is likely that the overall percentage of positive
responses in the Maryland county study is even
higher, they said, because nonfarm students out-
number farm students, who have earlier and more
frequent exposure to possible sources of the fungus
in nature, by four to one.

The disease, which causes fever, abdominal
cramps and other symptoms, affects the lungs, spleen
and liver and may prove fatal. It is generally con-
tracted by adults from fungus-contaminated soil
but the exact mode of distribution of the fungus
is not understood.

Other recent studies supply growing evidence that
a number of the middle eastern seaboard states have
areas of very high prevalence of histoplasmosis, the
authors said.

“There is no longer doubt that histoplasmosis has
a wider distribution than is currently recognized,”
they said.

Turncoat Antibody Found
In Muscular Disorder

(Continued from Page 43)

been considered by us as sufficient proof of the
autoimmune cause of a disease,” the researchers
said. “Additional evidence might be furnished by
reproducing the disease in experimental animals by
active immunization. . . .”

Even if it is assumed that myasthenia has an
autoimmune cause, they added, the triggering mech-
anism of the immunologic derangement remains
unknown.

The disease most often affects the muscles of
the eyes, face, neck, throat, tongue, and lips al-
though other muscles may be affected later. It
causes a sleepy facial expression and abnormal
speech. Drug therapy provides symptomatic relief.

CALIFORNIA MEDICINE

Volume 97 DECEMBER 1962 Number 6

Serum Protein Profiles in Coccidioidomycosis

WILLIAM B. REED, M.D., Burbank,

CHARLES L. HEISKELL, M.D., Newport Beach.
CHARLES W. HOLEMAN, M.D., Bakersfield, and
CHARLES CARPENTER, M.D., Los Angeles

Coccidioidomycosis is usually a relatively benign,
self-limited infection. In a few patients, however,
the primary pulmonary infection is followed by pro-
gressive dissemination that may involve almost any
system of the body except the gastrointestinal tract.
Because of the ominous prognosis that goes with
dissemination, it would be beneficial to have addi-
tional objective laboratory tests to evaluate the clin-
ical course and activity of the infection. To explore
one possibility, the authors measured the inflamma-
tory process of 40 patients with coccidioidomycosis,
using the new electrophoretic and immunochemical
techniques now being developed (gamma globulins,
alpha! and alpha2 protein and glycoprotein), and
compared the results with those of complement fix-
ation and skin tests with coccidioidin and with the
results of conventional laboratory tests.

METHODS

The subjects were 40 consecutive patients ad-
mitted to the Kern County General Hospital, Bakers-
field, with the diagnosis of coccidioidomycosis.

Assistant Clinical Professor of Medicine (Dermatology), University
of Southern California School of Medicine, Los Angeles (Dr. Reed);
Assistant Professor of Medicine, University of California School of
Medicine, Los Angeles (Dr. Heiskell); Staff, Kern County Hospital,
Bakersfield (Dr. Holeman); Professor and Chairman, Department of
Infectious Diseases, University of California School of Medicine, Los
Angeles 24 (Dr. Carpenter).

Submitted July 30, 1962.

• Serum protein analysis is a valuable addition
to the present methods for evaluating the status
of the individual patient with coccidioidomycosis.
The albumin protein and albumin glycoprotein
decrease and gamma protein increases in rela-
tion to severity of infection. In 40 patients with
coccidioidomycosis, changes in individual pro-
tein fractions could be significantly correlated
with conventional laboratory tests, such as the
complement fixation test, erythrocyte sedimenta-
tion rate and hematocrit.

Changes in the alpha- glycoprotein concentra-
tion, the erythrocyte sedimentation rate and the
hematocrit value appear to be related to the de-
gree of inflammation, while the changes in the
gamma protein and the beta2 glycoprotein ap-
pear to be related to the specific antibody re-
sponse.

These patients, 30 men and 10 women, represented
a fairly typical cross-section of those seen in a
county hospital in an endemic area. Their disease,
on the basis of its clinical activity, could be divided
into four classifications: primary pulmonary infec-
tion (nine patients) ; benign residual coccidioidal
lesions of the lungs or pleura (four patients) ;
chronic dissemination (23 patients) ; and menin-
gitis (four patients, one with additional dissemina-
tion elsewhere, and another with a resolving benign
lung lesion).

VOL. 97, NO. 6 • DECEMBER 1962

333

In addition, the patients were grouped according
to the physician’s clinical estimate of the severity of
infection into those with “mild” (14 patients),
“moderate” (17 patients), and “severe” (nine pa-
tients) disease. Placement into one of these groups
was made largely on the patient’s general appear-
ance and clinical course, without consideration of
any laboratory data.

CONVENTIONAL LABORATORY METHODS AND RESULTS

Coccidioidin, a filtrate of liquid cultures of Coc-
cidioides immities, is used for the various tests to
measure the status of the disease, such as the skin
test, precipitin test and complement fixation test.*

In a “positive” skin test, coccidioidin injected
intradermally produces a delayed reaction that is
read after 24 and 48 hours. This indicates that the
patient has, or has had, an infection with Coccidio-
ides immitis. Almost all patients will have a positive
skin reaction after the third week of their infection.
Repeated testing does not sensitize the patient’s skin
to the antigen, nor does it result in a rise in the
complement fixation or precipitin titers. The skin
sensitivity cannot be passively transferred.10 Pa-
tients with primary infection and erythema nodosum
usually show pronounced hypersensitivity upon skin
testing.14 When dissemination occurs, skin reactivity
may decrease or disappear. Sensitivity to skin test-
ing does not rule out dissemination, but indicates
rather that the individual patient may still possess
significant resistance to the infection.14

All patients in this study were skin tested. If the
result of the first skin test (1:100 strength) was
negative, a second test with 1:10 strength was done.
Of the 40 patients, 17 had positive reaction with the
1:100 strength, seven with the 1:10 strength, and 16
were negative with both strengths. With increased
severity of disease, the skin responses were less dis-
tinct. Of the 23 patients with dissemination in this
series, four were positive to 1:100 strength, seven
were positive to 1:10 strength but not to 1:100, and
12 were negative to both strengths.

The precipitin test is useful in establishing the
diagnosis, but it has little prognostic significance.
Precipitins usually appear in the serum after the
skin test becomes positive, but disappear after three
or four months.11,12 The complement-fixing anti-
bodies, if they subsequently appear, develop more
slowly than the precipitins. A rising titer usually
indicates the infection is of progressively increasing
severity, while regression usually means the infec-
tion is waning. A persistently high titer suggests the
possibility of chronic dissemination. The comple-
ment fixing antibodies do not seem to offer the pa-
tient any protection from the infection. Complement

* References 1, 2, 5, 8, 10.

fixation tests were performed on all 40 patients in
this study. There appeared to be less reactivity to
the skin test in those patients having the higher com-
plement fixation titers.

In this series, the authors considered those pa-
tients with coccidioidal meningitis as a separate
group because they felt that the skin test and the
complement fixation titer did not accurately indi-
cate the prognosis when meningitis is present. The
complement fixation test may be positive in a low
titer and the skin test may be strongly positive,
while the opposite may be seen in other forms of
dissemination. Isolated meningitis can occur with-
out evident involvement of other systems, as a result
of early seeding of the meninges during the acute
pulmonary infection.

Other blood tests that are clinically useful in
prognosis and objective evaluation of the infection
include the leukocyte count, the eosinophil count,
the hematocrit value and the erythrocyte sedimenta-
tion rate. Leukocytosis roughly indicates the severity
of the primary infection, but it has questionable
significance with regard to dissemination. Eosino-
philia may be associated with erythema nodosum,
which is considered a favorable prognostic sign, but
on the other hand, high eosinophil counts may be
observed in prolonged pulmonary infiltration and
may herald dissemination of the infection.3

The complement fixation titer, erythrocyte sedi-
mentation rate and mean hematocrit value were all
significantly different in the three categories grouped
by clinical estimates of severity of infection. The
complement fixation titers and erythrocyte sedimen-
tation rates progressively increased with severity of
infection, but there was considerable overlap of the
values from group to group. There was relatively
little difference between the hematocrit values of the
patients with “mild” disease and those with “mod-
erate” disease. The lowest hematocrit values were
usually associated with severe infection, and the
authors found almost no overlap between the he-
matocrit values of the patients with “severe” infec-
tion and those patients with “mild” or “moderate”
infection.

C-reactive protein was significantly associated
with a progressive increase in severity of infection.
Only two of fourteen patients with “mild” disease
had positive reaction, while 18 of 26 patients with
“moderate” or “severe” infections had positive
reaction.

Progressive infection is frequently associated with
increased globulin and decreased albumin in the
serum. Simple chemical determinations of these pro-
teins have been used empirically by some clinicians
as aids in evaluating the severity of the disease. For
example, in another study, the serum albumin and
globulin levels were determined in 25 cases of dis-

334

CALIFORNIA MEDICINE

Chart 1. — Mean serum protein profiles (absolute con-
tent of patients with relatively “mild” (1), “moderate”
(2), and “severe” (3) coccidioidomycosis. Normal mean
(m) and standard deviation (cr) indicated by horizontal
lines.

seminated coccidioidomycosis before and after am-
photericin-B therapy.7 Before treatment, the mean
albumin level was 3 gm. per 100 cc. in these pa-
tients, and the mean globulin level was 3.9 gm. per
100 cc. After three months of therapy, the mean
albumin level had risen to 4 gm. per 100 cc. and the
mean globulin level had fallen to 2.8 gm. per 100 cc.

IMMUNOCHEMICAL METHODS

Serum was stored at -10° C. and remained in a
thawed state for not more than 24 hours before use
in testing. Total serum proteins and glycoproteins
were determined by the methods of Weimer and
Moshin.13 Serum electrophoretic patterns were de-
termined with the Spinco system,9 using the peri-
odic-acid-Schiff stain and the Model RB Analytrol
for quantitation. C-reactive protein levels were de-
termined by a quantitative gel-diffusion technique.4

The absolute protein and glycoprotein content in
each electrophoretic fraction was computed from the
product of the total serum concentration and the
relative per cent of total migrating in the individual
electrophoretic fractions.

Alb. a-1 a-2 p-1 p-2 y-1 y-2 pt yt

Chart 2. — Mean serum protein profiles (relative per
cent) of patients with relatively “mild” (1), “moderate”
(2) and “severe” (3) coccidioidomycosis. Normal mean
(m) and standard deviation (a) indicated by horizontal
lines.

IMMUNOCHEMICAL RESULTS AND COMPARISONS

Relationship of Electrophoretic Fractions to
Severity of Infection

Serum protein fraction concentration showing
significant differences related to progressive in-
creases in severity of infection include the follow-
ing: the total serum glycoprotein, gammaj protein,
alpha! glycoprotein, total beta-glycoprotein, albumin
protein and albumin glycoprotein. However, there
were no significant differences in the electrophoretic
patterns of glycoproteins when judged only by their
relative per cent distribution, except for a progres-
sive increase in the per cent migrating in the albu-
min fractions with increasing severity of infection.
The electrophoretic patterns of the proteins, how-
ever, showed significant differences with respect to
the per cent which migrated as gammaj protein and
albumin. With increasing severity of infection, there
was a progressive increase in the per cent migrating
as gamma! protein, and a progressive decrease in

VOL. 97, NO. 6 • DECEMBER 1962

335

the per cent migrating as albumin. (See Charts 1
and 2.)

Correlation of Electrophoretic Fractions
with Clinical Tests

Both the absolute and relative concentrations of
albumin and gammaj protein showed significant
correlations with the complement fixation titer and
the erythrocyte sedimentation rate, and to a lesser
degree, with the hematocrit. Both the absolute and
relative concentration of the alpha2 fraction showed
a significant positive correlation with the sedimen-
tation rate, a negative correlation with the hemato-
crit value, and no significant correlation with the
complement fixation titer.

The total serum glycoproteins showed a signi-
ficant correlation with the complement fixation titer
and the sedimentation rate, but not with the hemato-
crit values. Most of this increase was due to smaller
increases in the alpha2 and beta2 glycoprotein elec-
trophoretic fractions. The hematocrit correlated pos-
itively with the absolute and relative concentration
of glycoprotein in the albumin electrophoretic frac-
tion, but not with that in the alpha2 fraction.

Relationship of Serum Protein Profiles to the
Clinical Type of Disease

There were no characteristic serum protein profiles
for the various clinical types of disease. In the four
patients with meningitis, there was little alteration
of the protein patterns, although there were signifi-
cant increases in the alpha glycoproteins. Two of
these patients, however, also had lesions outside the
central nervous system (pulmonary in one, osseous
and cutaneous in the other) . The four patients with
solitary benign pulmonary or pleural lesions showed
relatively normal patterns for proteins and glyco-
proteins, except for increases in alpha! glycoprotein.
Alpha glycoprotein increases are associated with in-
flammation, and these increases may indicate con-
tinued active inflammation in these patients.

DISCUSSION

Of the laboratory tests currently used in the man-
agement of patients with coccidioidomycosis, it is
generally thought that the complement fixation test
offers the best guide to the severity of the infection.
Even when this test is readily available, however,
there is always need for additional objective and in-
dependent laboratory tests to aid in the management
of coccidioidomycosis. The serum protein profile,
when judiciously interpreted in the light of other
clinical and laboratory data, is a valuable additional
measure of the severity of the infection.

Unlike the results of complement fixation test, the
abnormalities of the serum protein profile have no
diagnostic or etiologic specificity. The available clin-

ical evidence indicates that the total serum glyco-
proteins, particularly those of the alphai and alpha2
fractions, primarily reflect inflammation. It is widely
thought that the increases in the gamma proteins,
and possibly the beta2 proteins, reflect to some ex-
tent antibody formation. However, recent studies
have demonstrated considerable physico-chemical
and immunological heterogeneity of these fractions,
and it is likely that, in patients with very high val-
ues, only a relatively small portion of this fraction
would consist of specific antibodies to Coccidioides,
when considered gravimetrically.

The data of this study suggest that variations in
the complement fixation titer, erythrocyte sedimen-
tation rate and hematocrit value possibly reflect
different patho-physiologic phenomena. The comple-
ment fixation titer, presumably a direct measure-
ment of specific antibody response, shows a sig-
nificant correlation with the absolute and relative
concentrations of gamma globulin which is consist-
ent with an antibody response. It is assumed that the
negative correlation with albumin is due primarily
to the non-specific decrease in this fraction observed
in most severe infections or inflammatory diseases
associated with the indirect nutritional effects on the
serum proteins.

The correlation of the sedimentation rate with the
alpha2 protein and glycoprotein fractions is less eas-
ily explained. Increases in the sedimentation rate
have been attributed to increased fibrinogen, globu-
lins and haptoglobulins. Previous studies of serum
protein profiles in other infectious and inflammatory
diseases demonstrated a correlation between the
alpha2 protein, particularly the alpha2 glycoprotein
fraction, and the degree of inflammation.6 Assuming
this relationship exists in coccidioidomycosis, the
erythrocyte sedimentation rate would appear to cor-
relate with the degree of inflammation as well as
with the antibody response.

The hematocrit was relatively normal in the pa-
tients with “mild” or “moderate” infections, with
relatively little depression until the infection was
“severe.” There was also relatively less correlation
between the hematocrit and the protein electropho-
retic fraction. The relative concentration of the albu-
min and alpha2 glycoprotein fractions, however,
showed a closer correlation.

The physician’s clinical estimate of the severity
of the infection correlated closely with many of the
objective laboratory determinations. The value of
the hematocrit in estimating severity of infection is
limited somewhat by the lack of a significant de-
crease until the infection has become extensive. The
small overlap of values of patients with “severe” in-
fections and those of patients having “mild” and
“moderate” infections indicates a relatively high de-
gree of specificity.

336

CALIFORNIA MEDICINE

The complement fixation titer showed more varia-
tion due to severity of infection than did the erythro-
cyte sedimentation rate. The increase in these two
measurements was also progressive through all three
clinical categories, indicating their value in detect-
ing dissemination following the primary infection.
The complement fixation titer appears to be the
more reliable of the two, because of its specificity
and possibly its greater sensitivity. However, it is
difficult to perform and is not widely available; and
the erythrocyte sedimentation rate will usually be
the more useful as a routine test in clinical manage-
ment, with the complement fixation test used only
at monthly or bi-monthly intervals.

Testing for C-reactive protein, which is never
found in the serum of healthy patients and is usu-
ally associated with clinically significant inflamma-
tion, may sometimes be useful in the clinical
management of patients with coccidioidomycosis.
Most patients who had extensive pulmonary or extra-
pulmonary disease had C-reactive protein in their
serum, while those with mild infections usually did
not. The principal limitation of this test is its non-
specificity, in that it may also be positive due to
inflammation from causes other than coccidioidomy-
cosis.

The applications of serum protein analysis in the
clinical management of coccidioidomycosis requires
more extensive evaluation, particularly extended
serial studies in individual patients. It compared
favorably in this cross-sectional study with other
methods for estimating the extent of disease. It is
more easily standardized than the complement fixa-
tion test, but lacks its diagnostic specificity. The
main value of the serum protein analysis will prob-
ably be as an additional, independent and objective
laboratory test which may be clinically useful in
measuring the response of the host to his disease.

ACKNOWLEDGMENTS

The authors gratefully acknowledge the valuable assist-
ance that was given in this study by Charles E. Smith,

M.D., University of California School of Public Health,
Berkeley; J. Walter Wilson, M.D., University of California
School of Medicine, Los Angeles; Marjorie Biddle, Ph.D.,
Los Angeles County General Hospital; and Norman Levan,
M.D., University of Southern California School of Medicine,
Los Angeles.

1013 West Olive Blvd., Burbank (Reed).

REFERENCES

1. Cooke, J. V.: Immunity tests in coccidioidal granuloma,
Proc. Soc. Exper. Biol, and Med., 12:35, 1914.

2. Davis, D. J.: Coccidioidal granuloma with certain sero-
logical and experimental observations, Arch. Dermat. and
Syph., 9:577-587, 1924.

3. Fiese, M. J.: Coccidioidomycosis, Charles C. Thomas,
Springfield, Illinois, 1958.

4. Fukuda, M., Heiskell, C. L., and Carpenter, C. M.: A
method for quantitative determination of C-reactive protein
using gel-diffusion, Am. J. Clin. Path., 32:507-512, 1959.

5. Hassid, W. Z., Baker, E. E., and McCready, R. M.: An
immunologically active polysaccharide produced by Coc-
cidioides immites, J. Biol. Chem., 149:303-311, 1943.

6. Heiskell, C. L., Carpenter, C. M., Weimer, H. E., and
Nakagawa, S.: Serum glycoproteins in infectious and in-
flammatory diseases, Ann. New York Acad. Sci., 94:183-209,
1961.

7. Holeman, C. W.: Unpublished data.

8. Jacobson, H. P.: Coccidioidal granuloma: specific al-
lergic cutaneous reaction: experimental and clinical investi-
gations, Arch. Dermat. and Syph., 18:562-567, 1928.

9. Model R Paper Electrophoresis System Instruction
manual, Beckman, Spinco Division, Stanford Industrial
Park, Palo Alto, California.

10. Smith, C. E., Saito, M. T., Beard, R. R., Kepp, R. M.,
Clark, R. W., and Eddie, B. U.: Serological tests in the
diagnosis and prognosis of coccidioidomycosis, Am. J. Hyg.,
52:1-21, 1950.

11. Smith, C. E., Saito, M. T., and Simons, S. A.: Pattern
of 39,500 serologic tests in coccidioidomycosis, J.A.M.A.,
160:546-552, 1956.

12. Smith, C. E., Whiting, E. G., Baker, E. E., Rosen-
berger, H. G., Beard, R. R., and Saito, M. T.: The use of
coccidioidin, Ann. Rev. Tuberc., 57:330-360, 1948.

13. Weimer, H. E., and Moshm, J. R.: Serum glycopro-
tein concentrations in experimental tuberculosis of guinea
pigs, Am. Rev. Tuberc., 68:594-602, 1952.

14. Wilson, J. W. : Coccidioidomycosis as a tool in the
study of granulomatous disease, Calif. Med., 78:257-262,
1953.

VOL. 97, NO

DECEMBER 1962

337

Single-Dose Treatment of Enterobiasis

Use of a New Piperazine-Senna Preparation

JOHN T. RAGAN, M.D., Beverly Hills

Pinworms are commonly encountered in pediatric
practice. In a study of pinworm infestation in San
Francisco some years ago an incidence of 29 per
cent in boys and 34 per cent in girls was noted.10
In a more recent investigation of infestation in
children in a housing development for married
ex-servicemen studying at the University of Cali-
fornia at Los Angeles, the incidence was 43.3 per
cent.11 Several other studies2,7,10 suggest that a 30
to 40 per cent incidence is common among white
children in various parts of the country.

It has generally been considered that pinworm
infestation is relatively harmless and, except for
pruritus ani, largely asymptomatic. Recently, how-
ever, in a report of a ten-year study, Litter5 cited
instances of a number of rather severe pathological
consequences of enterobiasis, the variety implicating
the fields of dermatology, gastroenterology, gyne-
cology, neurology, proctology, psychiatry and
others. As far as we have been able to observe,
symptomatology has been limited to pruritus, ir-
ritability and restlessness, anorexia, insomnia, ab-
dominal pain and excoriations of the anal, perianal
and rectal areas. Prolonged insomnia and irrita-
bility can, of course, result in behavioral difficulties,
and anorexia can cause physical damage.

Until the advent of piperazine less than a decade
ago, pinworm therapy was a comparatively uncer-
tain undertaking. Piperazine quickly emerged as the
drug of choice because of its efficacy and relative
lack of toxicity. Even with this drug, however, there
is the problem of administration on seven suc-
cessive days, a rather cumbersome procedure,
particularly with young children. Currently, pyrvin-
ium pamoate, a cyanine dye, is employed and is
effective in a single dose. It does cause vomiting
in some young patients, however, and the dye stain
presents problems, particularly since its appearance
in the stool creates alarm even among some previ-
ously-warned parents.

According to recent reports in the literature,3,9,12
a new preparation combining time-tested piperazine
and standardized senna has proved effective in
treating enterobiasis with a single dose and without
significant side effects. Presumably, the piperazine

Submitted July 10, 1962.

• A preparation combining piperazine and
senna was clinically tested among 31 families in
which at least one member was found to be
positive for enterobiasis by the customary cello-
phane-tape anal smear technique. The diagnostic
smears were positive for 58 of those tested.
Following a single dose of piperazine-senna mix-
ture, all patients were cleared of the infestation
as determined by the customary criteria for
cure. In six patients in two families, reinfestation
occurred in two to three months after the first
administration. All were again cleared with one
dose of the mixture.

Side effects were insignificant and transient.
One 4-year-old child vomited, but an hour later
ingested a second dose without incident. The
preparation was palatable and easily adminis-
tered.

acts by narcotizing the worms, and the senna flushes
them out before they can recover.12

METHOD AND MATERIALS

All members of thirty-one families, in which at
least one member was found to be positive for
enterobiasis by the usual modified National Insti-
tutes of Health scotch-tape smear technique, were
administered the new piperazine-senna preparation*
in palatable chocolate-flavored granular form. Early
in the study, in an effort to determine the optimal
procedure, patients were given varying instructions
concerning the time of administration. In the latter
stages, the patients were directed to take the prep-
aration before or at breakfast. They were told they
could take it directly from a spoon or in milk or
on cereal. All were instructed to record reactions
at the time of ingestion and subsequent bowel move-
ments. They were given dated slides and scotch-tape,
and instructed in the technique of anal smears.
Starting on the eighth day after treatment, these
were taken on six consecutive mornings before
bathing or wiping the anal areas. A seventh post-
treatment smear was taken in the office by the in-
vestigator on the morning after the sixth smear.
All pretreatment diagnostic smears were adminis-
tered personally by the investigator, and all slides,

‘Pripsen Granules, supplied by the Medical Department of The
Purdue Frederick Company, New York, N. Y.

338

CALIFORNIA MEDICINE

pretreatment and post-treatment, were examined by
the investigator.

For children up to six years of age the dose
prescribed was one level teaspoonful of the mixture,
each teaspoon containing 1 gm. of piperazine phos-
phate and the standardized concentrate of 450 mg.
of senna pods. For children of six to eleven years
the dose was two teaspoonfuls, and for adults four
teaspoonfuls. There were no children older than
11 years.

For purposes of the study, only patients with
positive pretreatment smears were included in the
results. If all seven post-treatment smears were
negative, the treatment was evaluated as successful.

RESULTS

A total of 58 patients, including 54 children from
6 months to 11 years and four adults, had positive
diagnostic smears. The ages of the 54 children
averaged 4 years, with seven under one year, 22
from 1 to 3 years, 19 from 4 of 8 years, and six
over 8 years. Of the children, 33 were female and
21 male. The adults included two couples, one with
three children and the other with four children
positive for enterobiasis. Eighteen of the 58 had no
symptoms. In 21, the only symptom was pruritus.
Other symptoms — singly, or combined with pruritus
or with one another- — included severe irritability
and restlessness, anorexia, insomnia, abdominal pain
and pronounced lethargy. Physical findings included
excoriations in the anal, perianal and rectal areas.
Worms were seen only in one case.

All 58 patients were evaluated as cured* with a
single dose of the preparation. In six cases, however,
there was reinfestation from two to three months
later initially manifested in a recurrence of pruritus.
Two of the six were siblings who had had positive
smears before treatment, and the other four were
the parents and two out of four siblings of another
family, all of whose members had had positive
smears the first time. In each case, a single dose
of the preparation again resulted in eradication of
the pinworm. Counting only those who had positive
smears before treatment, there were thus 64 separate
administrations of the piperazine-senna pod mix-
ture, all of which resulted in eradication of pin-
worm infestation following a single dose.

In 35 of these 64 cases there were no side effects
whatever reported, and in another 24 the only effects
were transient looseness of bowels or slight and
transient cramps. In none of these 24 cases were
the side effects of any significance. Three other
patients had cramps, but all of them had complained
of intermittent cramps before the study. One other

* Cured is here used to mean cleared of evidence of infestation
as determined by the scotch-tape smear technique.

patient, a mother, said she thought she had cramps
but that they might have been psychologically in-
duced by the instructions. One patient, a 4-year-old
boy, vomited on first administration of the prepara-
tion. An hour later, he ingested a dose without
difficulty. There were no cases of true diarrhea and
none in which hydration was affected — an important
safety consideration where young children are con-
cerned.

There were 68 members of the 31 families in
the study who had negative diagnostic smears. All
were given the medication in the same manner as
those with positive smears. All of them still were
negative on post-treatment examination with seven
successive daily anal smears.

COMMENT

In this study, the piperazine-senna combination
appeared to have medical characteristics approach-
ing those recently described as ideal for enterobiasis
therapy8: the effective cure rate was 100 per cent;
it was non-toxic in the doses given, and both
piperazine1 and senna4 are reported to be non-toxic
in large doses; it was palatable and easily admin-
istered; and its efficacy with a single dose makes it
suitable for mass administration to family groups
and institutional populations.

Its palatability made it considerably more accept-
able than has been our experience with pyrvinium
pamoate or piperazine alone — an advantage particu-
larly in treatment of young children. Although side
effects were minimal as compared with pyrvinium
pamoate, it appears in retrospect that the incidence
of minor cramping and loose stools might have been
lessened by a reduction in dose for children of
3 years and under, without loss of efficacy. Two-
thirds of the patients who had these side effects
were in this age group. All received a teaspoonful
of the preparation. It was also our clinical im-
pression that there was far less cramping reported
by patients who were administered the test material
in the morning, before or at breakfast.

The single-dose effectiveness of the piperazine-
senna preparation simplified administration enor-
mously in comparison with piperazine alone. Al-
though none of the studies carried out by other
investigators with this preparation achieved 100 per
cent cure with the one dose, as ours did, they did
demonstrate a high degree of efficacy — ranging
from 93.3 per cent3 to 97 per cent.9

435 North Roxbury Drive, Beverly Hills.

REFERENCES

1. Bueding, E., and Swartzwelder, J. C. : Anthelminitics,
Pharmacol. Rev., 9:329, Sept. 1957.

VOL. 97, NO. 6 • DECEMBER 1962

339

2. Bumbalo, T. S., Plummer, L. J., and Warner, J. R.:
The treatment of enterobiasis in children, Am. J. Trop.
Med., 7:212, Mar. 1958.

3. Eidal, R. A., Wilde, B. D., Thomas, G. G., Hahn, F. L.,
and Shapard, R. I.: A new single-dose piperazine prepara-
tion for the treatment of enterobiasis, J. New Drugs, 1:122,
May-June 1961.

4. Hawkins, D. B.: Action of senna, Brit. M. J., 1:281,
Feb. 1, 1958.

5. Litter, L. : Pinworms — a ten-year study, Arch. Pedi-
atrics, 78:440, Nov. 1961.

6. Pryor, N. B.: Oxyuris vermicularis: The most prevalent
parasite encountered in the practice of pediatrics. J. Pedi-
atrics, 46:262, March 1955.

7. Rachelson, M. H., and Ferguson, W. R. : Piperazine in

the treatment of enterobiasis, Am. J. Dis. Child., 89:346,
Mar. 1955.

8. Royer, A., and Berdnikoff, K.: Pinworm infestation in
children : The problem and its treatment, Canad. Med. Ass.
J., 86:60, Jan. 13, 1962.

9. Stadler, H. E.: Single-dose therapy in enterobiasis:
Evaluation of a new piperazine preparation, J. Indiana St.
Med. Ass., 55:604, May 1962.

10. Stoll, N.: This wormy world, J. Parasitol., 33:1, Feb.
1947.

11. Turner, J. A., and Johnson, P. E., Jr.: Pyrvinium
pamoate in the treatment of pinworm infection in the home,
J. Pediatrics, 60:243, Feb. 1962.

12. White, R. H. R., and Scopes, J. W.: A single-dose
treatment of threadworms in children, Lancet, 1:256, Jan.
30, 1960.

340

CALIFORNIA MEDICINE

Viral Hepatitis

A Study of Hyperbilirubinemia with Acholuria in Convalescence

ALLAN G. REDEKER, M.D., Los Angeles, and ARTHUR KAHN, Kansas City, Kansas

Early in the course of viral hepatitis, bilirubin
may appear in the urine before an increase in the
total or 1-minute bilirubin level in the blood.3 On
the other hand, Watson6 pointed out that during
the late defervescent stage of infectious hepatitis,
bilirubinuria may be absent in the presence of
surprisingly high levels of total and 1-minute serum
bilirubin.

The study here reported was made in order to
further document the relationship of serum and
urine bilirubin levels during the defervescent stage
of viral hepatitis and to attempt to correlate the
1-minute and indirect bilirubin levels in the blood
with the disappearance of bilirubin from the urine.

METHODS

Forty-two patients with acute viral hepatitis were
the subjects of this study. Four were presumed
(from clinical history) to have serum hepatitis, and
the remainder infectious hepatitis. All patients were
in hospital during the course of the study. The
diagnosis of acute viral hepatitis was based on
history, clinical and biochemical features. As soon
as the diagnosis of acute hepatitis was ascertained,
the first morning urine specimen was examined
daily for bilirubin. The Ictotest,®* * which is sensi-
tive to 0.05 mg. of bilirubin per 100 ml. of urine,2
was used for the daily qualitative urine bilirubin
determinations. On the first day that a negative
result by the Ictotest examination was obtained, a
specimen of blood was then taken for determination
of the 1-minute direct and total bilirubin by the
van den Bergh reaction. On the succeeding day, the
urine was again examined for bilirubin. In no
instances did bilirubinuria reappear at that time,
although in a few instances mild relapses with
bilirubinuria did occur some days later.

RESULTS

The results of the serum van den Bergh reaction
on the day the urine was first free of bilirubin (as
determined by the Ictotest) are recorded in Table 1.

From the Department of Medicine, School of Medicine, University
of Southern California, Los Angeles; and the John Wesley County
Hospital, Los Angeles.

Submitted May 21, 1962.

*A simplified test for determination of bilirubin in the urine.
Material supplied by Ames Laboratories.

• In 42 patients convalescing from viral hepa-
titis, the total and 1-minute serum bilirubin
levels were measured on the day bilirubin was
first demonstrated to be absent from the urine.

The levels of total bilirubin ranged from 0.5
to 6.2 per 100 ml. of blood (mean 2.8 mg.),
while the levels of the 1-minute bilirubin ranged
from 0.3 to 3.3 mg. per 100 ml. of blood (mean
1.5 mg.).

The reason for acholuria in the presence of
the elevated 1-minute direct van den Bergh
measurements is not clear, but may be due to
the failure of the van den Bergh reaction to
accurately measure the exact concentrations of
free and conjugated bilirubin present in the
plasma.

Twenty-seven of the 42 patients (64.3 per cent)
had 1-minute direct-acting serum bilirubin levels
which equaled or exceeded the indirect value at a
time when the urine was free of bilirubin. More-
over, 11 of the 42 patients (26 per cent) had a
1-minute serum bilirubin greater than 2.0 mg. per
100 ml. Thirty-eight patients (90.5 per cent) had a
total serum bilirubin greater than 1 mg. per 100
ml., and in the remaining four cases the 1-minute
direct fraction was abnormally elevated, averaging
68 per cent of the total.

DISCUSSION

Neefe and Reinhold demonstrated bilirubin in
the urine in 75 per cent of a group of patients with
early, developing infectious hepatitis when the
1-minute direct bilirubin was less than 0.25 mg. per
ml. of blood.3 In marked contrast, in the current
study of patients convalescing from viral hepatitis,
the urine was free of bilirubin although the 1-
minute direct measurement invariably exceeded 0.3
mg. per 100 ml. of blood and ranged as high as
3.3 mg. per 100 ml. In fact, the mean level of 1-
minute direct bilirubin associated with acholuria
was 1.5 mg. per 100 ml. of blood. It should be
noted, however, that there was considerable varia-
bility in the blood levels of total and 1-minute direct
bilirubin at which acholuria first appeared. It is
apparent that there is no predictable level of either
fraction at which acholuria can be expected in
convalescent viral hepatitis.

VOL. 97, NO. 6 • DECEMBER 1962

341

TABLE 1. — Results of Bilirubin Determinations in 42 Patients
Convalescing from Viral Hepatitis

Case No.

Total Serum
mg. per

100 ml.

Indirect
mg. per

100 ml.

1-minute
van den Bergh

mg. per Per Cent

100 ml. Direct

2.8

0.9

1.9

67.8

5.3

2.8

2.5

47.2

6.2

3.4

2.8

45.2

3.5

1.5

2.0

57.2

1.3

1.0

0.3

23.1

3.8

1.6

2.2

57.9

4.2

1.7

2.5

59.5

1.8

0.9

50.0

2.5

1.2

1.3

52.0

3.1

1.5

1.6

51.6

3.3

1.9

1.4

42.4

0.7

0.3

0.4

63.0

3.7

1.9

1.8

48.7

4.4

2.3

2.1

47.7

2.3

0.6

1.7

73.9

4.4

2.5

1.9

43.2

2.0

1.0

50.0

2.5

1.0

1.5

60.0

5.8

2.5

3.3

56.9

4.1

1.8

2.3

56.2

1.4

0.5

0.9

64.3

0.7

0.3

0.4

57.2

2.4

1.2

50.0

5.0

2.2

2.8

56.0

3.2

1.8

1.4

43.8

1.3

0.8

0.5

38.5

2.0

1.1

0.9

45.0

1.5

0.9

0.6

40.0

3.7

1.6

2.1

56.8

1.9

0.9

1.0

52.6

2.2

1.3

0.9

40.9

2.9

1.4

1.5

51.7

2.7

1.4

1.3

48.3

2.1

0.5

1.6

76.2

2.1

0.5

1.6

76.2

2.9

1.5

1.4

48.3

3.1

1.3

1.8

58.1

1.6

0.8

50.0

0.8

0.4

50.0

0.5

0.0

0.5

100.0

2.8

1.4

50.0

5.0

2.7

2.3

46.0

Mean

2.8

1.3

1.5

54.0

Standard

deviation ....

±1.41

±0.73

±0.74

±12.6

Current concepts of bilirubin metabolism imply
that only bilirubin in a conjugated form escapes
into the urine.4 Bilirubinuria, then, should be ex-
pected whenever the level of conjugated bilirubin
in the plasma exceeds the “renal threshold.” The
results of this study are difficult to explain in the
light of these concepts.

The possibility that the “renal threshold” for
conjugated bilirubin is altered during the course
of viral hepatitis seems unlikely. On the other hand,
neither our data nor those of Watson6 suggest that
the injured liver in the convalescent phase of hepa-
titis has become diminished in its efficiency for
bilirubin conjugation. On the contrary, in the pres-
ent study the direct 1-minute fraction averaged 54
per cent of the total serum bilirubin in the con-
valescing hepatitis patients.

Possibly conjugates of bilirubin other than glu-
curonides — conjugates that are less readily excreted
into the urine — are formed during the course of
viral hepatitis. On the other hand, due to the com-
plex kinetics of the van den Bergh reaction, the
direct 1-minute fraction cannot be taken as an
exact measure of the concentration of conjugated
bilirubin. Brodersen,1 in a study of the velocities of
the phases of the diazo reaction, showed that serum
with a reaction velocity like that obtained with free
bilirubin may give as much as 30 per cent direct
bilirubin in the routine van den Bergh procedure.
In the routine van den Bergh procedure, the total
bilirubin is estimated after the addition of an
accelerator, alcohol, which allows the free bilirubin
to come into solution and react with the diazotized
sulfanilic acid. The possible presence of other
hydrophilic substances in plasma with solubilizing
properties similar to those of alcohol has been
mentioned.5 It is possible that such substances col-
lect in the plasma during the course of viral hepa-
titis, distorting the results of the van den Bergh
reaction in the convalescent phase of the disease.

2025 Zonal Avenue, Los Angeles 33 (Redeker).

REFERENCES

1. Brodersen, R.: Kinetics of the van den Bergh reaction.
Scand. J. Clin. & Lab. Invest., 12:25, 1960.

2. Free, A. H. and Free, H. M.: A simple test for urine
bilirubin. Gastroenterology, 24:414, 1953.

3. Neefe, J. R. and Reinhold, J. G.: Laboratory aids in
the diagnosis and management of infectious (epidemic)
hepatitis. Gastroenterology, 7 :393, 1946.

4. Schmid, R.: Some aspects of bile pigment metabolism.
Clin. Chem. (Supp.), 3:394, 1957.

5. Schmid, R.: Jaundice and bilirubin metabolism. Arch.
Int. Med., 101:669, 1958.

6. Watson, C. J.: Some newer concepts of the natural
derivatives of hemoglobin. Blood, 1:99, 1946.

342

CALIFORNIA MEDICINE

Indications for Operation in Glaucoma

ROBERT N. SHAFFER, M.D., San Francisco

Surgical operation for glaucoma is indicated
when, despite maximal medical therapy, the intra-
ocular pressure reaches a level at which the optic
nerve is going to be damaged, but putting that
simple principle into practice can be one of the
most vexing problems in ophthalmology. There are
some conditions in which the indications can be
stated positively and other conditions in which no
clean-cut decision can be made. It is the purpose
of this paper to present some of the criteria which
are useful in reaching a reasonable decision.

The two types of glaucoma in which the indica-
tion for operation is nearly absolute are infantile
glaucoma and angle-closure glaucoma. Rarely is
true infantile glaucoma spontaneously resolved;
most patients not successfully operated upon lose
their sight. Inherent in the diagnosis of infantile
glaucoma is a recommendation for prompt goni-
otomy.

In angle-closure glaucoma with pupillary block
there is also an almost absolute mandate to operate.
The mechanism of relative pupillary block which
results in most primary angle-closure glaucoma is
well understood. It is also accepted that iridectomy
permanently protects the eye from further attacks
of angle closure. The situation is almost unique in
that truly curative surgical operation is possible
if it is performed before permanent peripheral
anterior synechia or trabecular damage has been
produced. Therefore, iridectomy is indicated in
any case of angle closure as soon as pressures can
be brought into normal range by medical treat-
ment. Even if only one eye is affected, prophylactic
iridectomy probably should be done in the other.

There are few absolutes in medicine, and quali-
fications to the rule for iridectomy immediately
come to mind. Exceptions depend to a large degree
on the gonioscopic findings. If the angle opens to a
full grade 2 when miotic drugs are given, the need
for operation is less urgent. A patient who is elderly
or in poor health, or who has strong objections to
surgical operation, may be maintained by drug
therapy provided he is reliable about taking drugs
as prescribed.

The narrower the angle, the more imminent is
angle closure, and the more urgent the need for

Presented before the Section on Eye at the 91st Annual Session
of the California Medical Association. San Francisco, April 15 to 18,
1962.

• Prompt surgical operation is indicated in
angle-closure glaucoma and in infantile glau-
coma. Open-angle glaucoma is properly consid-
ered a disease for which conservative treatment
should be tried.

Operation is indicated in open-angle glaucoma
when, despite maximal medical therapy, the
intraocular pressure reaches a level at which the
optic nerve is going to be damaged. Many fac-
tors must he considered in making a decision
as to whether or not to operate in such circum-
stances, among them the condition of the eye,
the result of previous operation if one has been
done, the reliability of the patient with regard
to carrying out a prescribed regimen, the age
and physical condition of the patient, perhaps
the race of the patient, the presence of cataracts
and the attitude of both patient and surgeon
toward surgical treatment.

iridectomy. When properly performed, peripheral
iridectomy is as safe as any intraocular operation
can be, taking into account the final qualification:
the surgeon must be highly skilled.

Indications for operation in chronic open-angle
glaucoma are not as clear-cut as for the angle-
closure form. Operation does not cure open-angle
glaucoma. Often, reducing tension is accompanied
by decreased visual acuity due to corneal changes,
chronic iritis or lens opacity. When one adds to
this the fact that about 25 per cent of filtering
operations are unsuccessful, it is easy to see why
ophthalmologists prefer to control pressures medi-
cally if possible. Operation is obviously indicated
when consistently high intraocular pressures are
associated with cupping of the disc and progressive
changes in the visual field. There are many other
cases in which the decision can be made only by
the careful evaluation of many factors. The factors
to be considered are as follows:

Optic disc. A healthy, pink disc with no cupping
is a most favorable finding. It is believed that such
a nerve will withstand increased pressures longer
than will a cupped disc. In all cases, discs should
be diagrammed or photographed so that changes in
cupping with the passage of time can be recognized.
The more severely cupped and atrophic the optic
nerve head, the more urgent is the need to normal-
ize the intraocular pressure.

Field changes. Progressive changes in the visual
field in the presence of tension elevation are usually

VOL. 97, NO. 6 • DECEMBER 1962

343

considered reason for operation. One must be sure
that the changes are actual and not the result of
changes in technique of examination, in techni-
cians, in test object or in lighting, and that they
are not due to intraocular complication such as
cataract formation, retinal detachment or retinal
disease. Miosis of the pupil produced by the strong
miotic drugs will sometimes exaggerate an existing
field defect. It is also wise to correlate the apparent
field change with the appearance of the optic disc.
A pronounced field defect in the presence of a
healthy, pink disc casts doubt on the accuracy of
the field examination.

Tension. The higher the tension the more certain
it becomes that damage to the nerve is going to
occur. With normal discs and fields, tensions even
up to the level of 40 mm. of mercury may be
tolerated. However, most ophthalmologists become
increasingly alarmed as tensions go above 30 mm.
If the optic disc has already been damaged, opera-
tion should be performed promptly if the pressure
runs above 24 mm. or there is the least sign of
progression of disc or field changes.

In terminal glaucoma the field may be limited
to the few degrees around fixation. Obviously, any
further progression of the field defect will extin-
guish macular vision. For determining when opera-
tion must be done in such circumstances, reliance
must be placed on the tension elevations. If pres-
sures are consistently running between 24 and
30 mm. of mercury (Schiotz), it is wise to do a
filtering procedure on one eye, then on the other
if the result is favorable. If there is but one eye, it
is wiser not to operate unless the tension is fre-
quently above 30 mm. of mercury (Schiotz). Sur-
gical intervention risks macular hemorrhage or
edema, which may result in total loss of central
visual acuity. As a rule, however, an eye of this
description will tolerate operation.

Narrowness of the angles. Narrowness of the
angles is seldom a problem in open-angle glaucoma.
In a few cases, however, there may be an angle so
critically narrowed that the use of strong miotic
agents or epinephrine entails risk of angle closure.
Such a situation may require surgical intervention.
Even if a filtering operation fails, the accompany-
ing iridectomy permits a more energetic medical
regimen.

Reliability of the patient. Operation is indicated
in those patients who are mentally, physically or
psychologically unable to carry out the disciplined
therapy necessary for medical control of open-angle
glaucoma.

Age and physical condition of the patient. In
pre-presbyopic patients, the severe blurring of vis-
ion caused by miotic agents often results in irreg-

ular use of the drops and ineffective therapy.
Although the optic nerve in the young seems to
be more resistant to damage, any loss that does
occur in them is the more alarming because of their
long life expectancy. The younger the patient, the
more probable it is that operation will become
necessary.

The elderly are often more understanding of
the nature of chronic illness and of their personal
responsibility in maintaining visual function. Hence
for the most part they accept a medical regimen
with more determination and tolerance. If operation
becomes necessary, it seems to be more likely to
result in a filtering bleb because of the paucity of
subconjunctival connective tissue and decreased re-
activity of the tissues. On the other hand, there is
an increased risk of postoperative cataract for-
mation.

The race of the patient. Most surgeons believe
that filtering operations are less likely to be effective
in the Negro race than with Caucasians or Orientals.

Presence of cataracts. The presence of lens opaci-
ties is frequently a complicating factor in glaucoma.
In angle-closure glaucoma it is almost a welcome
finding, for removal of the lens deepens the an-
terior chamber and widens the angle if peripheral
anterior synechias have not formed. In this way
one procedure cures the glaucoma and restores
vision.

In open-angle glaucoma, a filtering procedure is
likely to result in rapid progression of pre-existing
lens opacities. Furthermore, if the glaucoma opera-
tion is successful its filtration may be spoiled by
subsequent cataract removal. Therefore, in general
it is better to remove a cataract before a glaucoma
operation is performed if vision is less than 20/50
and tension is not consistently above 35 mm. of
mercury.

Previous Operation. There is an ophthalmologic
maxim, “As the first eye goes, so goes the second.”
When good filtration develops in one eye after
operation, the outlook for a favorable result in the
other eye is improved. Conversely, if good filtration
is not brought about by a technically well done
procedure, the case for medical treatment is
strengthened.

Attitude of the patient and of the surgeon. Of all
the imponderables, the attitudes of the patient and
of the surgeon are the most difficult to assess. There
is no doubt that operation is undertaken much later
on patients who are reluctant to undergo the pro-
cedure than on those who welcome it. The surgeon’s
attitude is often influenced by the success or failure
of his most recent filtering operations rather than
by a dispassionate evaluation of the facts.

344

CALIFORNIA MEDICINE

COMMENT

The present concept of angle-closure and infan-
tile glaucoma as surgical diseases, and of open-angle
glaucoma as a medical disease, seems to be well
founded. A note of caution should be sounded,
however: Sometimes the eyes of a patient with
open-angle glaucoma are permitted to lose function
while the patient is being treated with miotic agents,
carbonic anhydrase inhibitors and epinephrine in
various proportions, combinations and timings.
This exploratory use of the medical agents is legit-
imate but should be completed promptly. It takes
only a few days to determine whether or not a
given combination is effective. The urgency with
which the search should be pursued depends on the
severity of the intraocular pressure and the vulner-
ability of the optic nerve.

It is unfortunate that no test exists by which
the threat to optic nerve function can be assessed.

There is good evidence that one important factor
is insufficiency of the vascular supply to the nerve.
Following this lead, some promising research is
being done by Harrington2 at the University of
California, and Drance1 at the University of Sas-
katoon. By use of an ophthalmodynamometer or a
Kukan suction cup, the intraocular pressure is in-
creased until a Bjerrum’s scotoma is produced. If
further experience confirms that permanent nerve
damage is imminent when this scotoma is produced
at low intraocular pressure levels, the surgeon will
be able to choose more precisely the proper time for
filtering operations.

490 Post Street, San Francisco 2.

REFERENCES

1. Drance, T. W.: Personal communication.

2. Harrington, D. 0.: Pathogenesis of the glaucomatous
visual field defects: Individual variations in pressure sensi-
tivity. Josiah Macy, Jr., Foundation Glaucoma Conference,
Fifth Conference, 1960.

VOL. 97, NO. 6 * DECEMBER 1 962 345

Psychiatric Aspects of Psychomotor Epilepsy

A. E. BENNETT, M.D., Berkeley

For GENERATIONS neurologists and psychiatrists have
recognized certain psychiatric disorders associated
with epilepsy. Peculiar clinical episodes without
convulsive seizure have been called psychomotor
epilepsy.

Hughlings Jackson, whose name has been at-
tached to focal seizures, described the syndrome
fully and related psychomotor attacks to temporal
lobe lesions. With the increased knowledge through
electroencephalography, showing a predominance of
temporal lobe involvement, the term temporal lobe
epilepsy is now used to designate the syndrome.

Of all the forms of epilepsy, this one is the least
understood. Undoubtedly epilepsy goes unrecog-
nized in a large number of cases because the pa-
tients have mental symptoms only. Such cases may
not all he of the psychomotor type. Unrecognized
epilepsy may show itself as irascible temperament or
feelings of hostility and surges of hatred without
overt seizures. Or the patients may have difficulty
in adjusting to life situations, occupations or social
relations, their behavior in a way often resembling
the schizoid pattern. Anxiety reaction in the form
of terrifying dreams, nightmares, peculiar fears,
queer head sensations, with apprehension and panic
without adequate psychogenesis may be a manifes-
tation of epilepsy. All persons acting paranoid, with
uncontrollable temper outbursts, should have elec-
troencephalographic examination to rule out seiz-
ure discharges. Such persons may have learned that
if they get into an argument they become violent.
Also, ingestion of alcohol may provoke uncontrol-
lable outbursts of temper.

Some epileptic persons have an associated psy-
chiatric disorder also — sometimes described as
hysteroid-epilepsy or as “epileptic personality.” Al-
though the psychiatric disorder is independent of
the epileptic process, it is more likely to appear in
patients with temporal lobe epilepsy. It will not
respond to anticonvulsant treatment alone. Other
treatment measures — drug therapy, psychotherapy
or even electroshock treatments — may have to be
used to clear the psychiatric disorder, while the epi-
leptic state may also require treatment.

Physicians generally seem not to he aware that
persons with epilepsy have spells that are like neu-

From the A. E. Bennett Neuropsychiatric Research Foundation and
Herrick Memorial Psychiatric Department.

Presented at Omaha-Midwest Clinical Society, Nov. 1, 1961.

Submitted April 20, 1962.

• Psychomotor or temporal lobe epilepsy is a
frequently missed diagnosis. It is often confused
with grand mal and petit mal epilepsy. At times
it is the first symptom of an organic neurological
disease. It is often masked as a psychiatric dis-
order or is associated with a mental illness with-
out clinically detectable seizures.

These psychic manifestations simidate all of
the neuroses and major psychiatric states. Excite-
ment states with amnesia may lead to violent
antisocial behavior. All these manifestations may
be aggravated by alcohol.

Thalamic epilepsy shows itself in similar psy-
chiatric manifestations and accounts for behavior
disorder in children more than temporal lobe
epilepsy. Atypical seizures with vegetative or
emotional aura and a characteristic electroen-
cephalogram differentiate it from temporal lobe
epilepsy.

Proper understanding of the varied manifes-
tations, with positive eleetroencephalographic
findings, leads to the correct diagnosis in most
cases. All patients with unusual or atypical per-
sonality or psychiatric-like states should have
careful eleetroencephalographic examination.
Anticonvulsant therapy and other psychiatric
treatment procedures can relieve most cases. Sur-
gical therapy sometimes is necessary.

rotic, manic-depressive or paranoid reactions. For
example, many epileptic persons drink to excess to
escape from emotional tension and yet after a small
amount of alcohol become transiently psychotic.
Others — those with character disorders, for example
— are just hard to live with, cannot get along with
people and often insult others. Aimless emotional
reactions of that kind, even in the absence of seizure
history, warrant eleetroencephalographic examina-
tion, for often the psychic equivalents of epilepsy or
temporal lobe epilepsy may be the cause. Fully half
of persons with difficult behavior problems, often
with a history of delinquent tendencies in child-
hood, have abnormal electroencephalograms similar
to those in epilepsy.

Probably 17 per cent of all epilepsy is of the tem-
poral lobe type, and 50 per cent of the patients have
serious psychological or mental disorders. Most of
the epileptic persons who are admitted to mental
hospitals have psychomotor epilepsy.

One or more of following clinical symptoms is
present in classical temporal lobe epilepsy: audi-
tory, olfactory or visual hallucination, experiential
illusions, macropsia, micropsia, deja vu phenome-

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non or automatic movements, and mental confusion
with semipurposeful activity.

Electroencephalography before or during attacks
shows spike activity and slow waves of 4 to 6 per
second with a focus in the anterior temporal areas,
spreading to other areas and, in severe cases, bilat-
eral. Often these can be activated by hyperventila-
tion sleep recording, by photic stimulation or by
administration of pentylenetetrazol (Metrazol®).

One must be sure tbe electroencephalographic in-
formation is accurate. Some machines are defective
and some technicians not skilled, not recognizing
artefacts or normal sleep patterns and interpreting
them as convulsive records.

Closely allied to temporal lobe epilepsy is tha-
lamic or hypothalamic epilepsy.2 Atypical seizures
occur, usually preceded by sensory, emotional or
vegetative aura suggesting thalamic onset of dis-
charges. The seizures take the form of unconscious-
ness of 30 seconds or more without convulsive
movement followed by drowsiness and, frequently,
head pain. The electroencephalogram shows 14 per
second and 6 per second positive spikes. Vegetative
symptoms also are a feature — gastric aura, abdomi-
nal pain, flushing, sweating, shivering or palpita-
tion. Psychiatric symptoms occur in 60 per cent of
cases, attacks of rage being the most frequent,
usually without complete unconsciousness although
partially amnesic. In children this pattern is more
frequent than the psychomotor or temporal lobe
pattern.

DIAGNOSTIC CRITERIA

Psychomotor or temporal lobe epilepsy is fre-
quently confused with other seizure states. Aird,1
in a comprehensive study of 204 patients, observed
that incorrect clinical diagnosis had been made in
83 per cent who had been treated for grand mal or
petit mal epilepsy. The most common source of error
was the neglect of finding of a temporal lobe firing
point in the electroencephalogram and the next
most common was the confusion of minor and brief
temporal lobe spells with petit mal epilepsy. Brief
psychomotor spells which show as a lapse of contact
with the environment resemble petit mal spells.
Other points of confusion were psychiatric disorders
and neurologic conditions, such as behavior dis-
orders in childhood, and migraine and cerebral
neoplasms. Several diagnostic criteria help differen-
tiate temporal lobe epilepsy from other forms. Usu-
ally a family history of epilepsy is lacking. Long
standing cases are usually from brain damage at
birth or later. Hyperactivity, hypersensitivity, intro-
spection. temper tantrums and irritability are com-
mon characteristics. Against this background the
patient usually has atypical spells, too prolonged for
petit mal, with impaired consciousness, including

periods of confusion, as well as episodes of dreamy
states and automatism.

The aura when present is diagnostic — uncinate
taste and smell, hallucination and cleja vu phenome-
non, followed by automatism, bizarre motor activity
or a mild tonic fit. The patient appears confused;
he may seem to recognize the physician but does not
reply to questions or merely mumbles; he seems
anxious, has repetitive actions, fumbles with cloth-
ing, handles objects or writes. The actions are pur-
poseless or inappropriate. The patient is ambulatory,
or if seated he may get up, move about or start to
undress and if resisted may meet force with force
or even violence. Excessive activity resembling psy-
chotic excitement states, with amnesia, may occur.
Careful electroencephalographic records, with stim-
ulation to activate latent cases, as previously de-
scribed, provides material for positive diagnosis in
about 90 per cent of cases. If the electroencephalo-
gram is normal but attacks are typical, the patient
should be treated as having temporal lobe epilepsy.

PSYCHIATRIC DISORDERS CONFUSED WITH EPILEPSY

Behavior disorders in both adults and children
may be of epileptic origin. The electroencephalo-
gram is the deciding factor; if it clearly displays
seizure discharges, the condition is presumably epi-
leptiform. Many patients, in addition to psychomo-
tor seizures, have periods of moodiness, negativity,
bad temper and increased irritability, even destruc-
tiveness.

A child may commit antisocial acts without
purpose — set fires, steal, run away, display temper
tantrums or have fits of screaming, crying or breath-
holding to the point of unconsciousness. Many
behavior disorders occur in children with brain dam-
age from trauma at birth, from high febrile states,
from encephalitis or blows to the head. Schwade,
and Geiser4 made electroencephalographic studies
of 100 patients (age 18 months to 16 years)
with severe behavior disorders characterized by ex-
treme aggressive or violent reactions. Seventy-three
per cent of them showed 6 to 14 per second spiking
confined to one temporal and the occipital areas,
with spread to the opposite side. It was felt this ac-
tivity originated in the thalamic area. These cases
fit best into Gibbs’ classification of thalamic epi-
lepsy.

Sarvis3 described the case of a boy with violent
outbursts associated with neurotic-like behavior. For
some time he was treated as having a psychogenic
disorder. Finally a diagnosis of organic brain syn-
drome, with electroencephalographic evidence of a
focal lesion in the right temporal lobe, was made.
Decided improvement was noted when an anticon-
vulsant drug was given. After four years, treatment

VOL. 97, NO. 6 • DECEMBER 1962

347

was discontinued and, when last examined some two
years later, the patient seemed normal.

The adult patients have mood shifts, from sweet
to sour, or may become abusive — worse under alco-
hol— or may have spells in which they just act
queerly or are simply “not themselves.” Irritations
that arouse only resentment to normal persons may
excite an epileptic patient to mania. Automatic
movements that are part of the seizure pattern often
are erroneously considered to be hysterical. Impair-
ment of consciousness is the essence of most epi-
leptic seizures; amnesia, partial or complete, is
evidence of unconsciousness. Other manifestations in
the adult may be dream states; fits of emotional
reaction, pleasure, depression, fear or compulsive
laughter. Hypnagogic states are twilight episodes
between sleep and awakeness. A sense of unreality,
inability to orient oneself to time or place, fragmen-
tary thoughts, deja vu — all are subjective psychic
attacks due to disturbance in consciousness and may
be called dizzy spells by the patient.

MEDICOLEGAL ASPECTS OF TEMPORAL LOBE EPILEPSY

Many horrible crimes are attributable to epilepsy.
Patients susceptible to automatism fugues or in
states of amnesia may react with extreme violence
at the least frustration. This tendency may be acti-
vated by alcohol.

Electroencephalographic studies by Thompson
and Marinacci5 upon psychomotor epileptic patients
after alcoholic indulgence showed activation of seiz-
ure discharges from the temporal lobe. Persons of
that order have committed crimes such as robbery,
murder and manslaughter. The ingestion of alcohol
lowers the threshold to a degree which varies be-
tween subclinical seizure and actual convulsion.

The observations are of extreme importance in
fixing responsibility in medicolegal cases. The syn-
drome has been called acute alcoholic psychosis of
the pathological intoxication type. Investigators be-
lieve they have established correlative evidence
between psychopathic personality, pathological intox-
ication and psychomotor epilepsy. The three disor-
ders seem to be variations of the same fundamental
cerebral disturbance. While persons with this dis-
order under the influence of alcohol are totally
irresponsible for their acts, they may not be so con-
sidered by judges and juries. Courts have not ac-
cepted alcoholic intoxication per se as an excuse for
criminal behavior.

The following case illustrates the problem. The
patient was sent to us for evaluation by the court
because he had brutally murdered his sister. A
grand mal seizure had been observed while he was
held in jail.

The patient was a 31-year-old American Indian.

A significant part of his history was of a drinking
problem for eight to ten years. Nocturnal spells de-
scribed as breath-holding attacks and frequent, al-
most daily momentary blackouts had occurred since
he was 21. He described one attack of passing out
while in an automobile and of coming to poorly
clad, outside the car, while attempting to push it.
He had been told by companions that he had had a
generalized convulsive seizure after a drinking
episode.

The patient had been arrested in a cheap hotel
after a prolonged drinking bout for murder of his
sister in a very brutal fashion. His story was a dis-
connected account of drinking with his sister in and
out of bars, over a period of about 48 hours, get-
ting into a fight and being found by police officers
with blood on his clothing. When accused of the
crime he confessed he must have committed it, but
later denied it and claimed he couldn’t remember
what had happened.

Upon examination, flatness of affect and complete
lack of insight into the seriousness of his pre-
dicament were noted. His psychological status was
characterized by severe cultural, educational and in-
tellectual limitations and schizoid character defects,
but with no evidence of organic disease.

An electroencephalogram showed generalized dys-
rhythmia with spike activity, aggravated by Metra-
zol® — a typically epileptic pattern.

This patient had grand mal and petit mal epi-
lepsy under the influence of alcohol. After a seizure
he had confusion, amnesic state and automatism for
hours, perhaps longer, and committed murder with
no memory of the act. Despite this medical evidence
of irresponsibility the patient was sentenced to life
imprisonment. He died within a year of unknown
cause.

DRUG THERAPY OF TEMPORAL LOBE EPILEPSY

The goal of successful drug therapy of temporal
lobe epilepsy should be to render the patient free of
seizures. A symptomatic treatment, it largely de-
pends upon the right choice of drugs for the kind
of seizure in each case. Of first importance is to
properly identify and classify the type of seizure or
seizures into grand mal, petit mal, psychomotor or
combinations of one or more types.

Phenobarbital alone or combined with dephenyl
hydantoin is the most useful and least toxic in
grand mal epilepsy, but is not usually effective in
petit mal or psychomotor cases. Drugs of the oxaxe-
lidine series (Paradione® and Tridione®) are only
useful in petit mal. Unfortunately they may be toxic
and the patient must be watched very carefully for
side effects.

Psychomotor epilepsy has not responded as well
to drug therapy as have the other forms, but some

348

CALIFORNIA MEDICINE

degree of control is obtainable. No single drug is
satisfactory. Phenacemide (Phenurone®) is the
most effective drug but often has dangerous toxic
reactions such as aplastic anemia and liver disease.
Nausea and anorexia are warning signs and liver
function tests must be done at frequent intervals.
Primidone (Mysoline®) is useful in some cases but
often cannot be taken because of unpleasant side
effects such as nausea, drowsiness and dizziness. It
is best to start with very small doses (0.125 gm.)
and gradually work up to tolerance of 1 to 2 gm.
over a period of two weeks.

Methsuximide (Celontin®) in 0.3 gm. capsules
up to four times a day is effective in both petit mal
and psychomotor epilepsy and is relatively free from
side effects. Some observers consider it the drug of
choice in psychomotor states. Some patients become
resistant to certain drugs, or the type of their attacks
changes. The least toxic drugs such as methsuximide
or brimidone should be tried first, singly to start
with, then in combination if necessary. Phenacemide
can be reserved for use if these measures fail. In
refractory cases it may be necessary to try various
combinations in order to bring the seizures under
control. There is need for much research to find
less toxic drugs for the management of psychomotor
attacks.

In certain cases where the psychomotor attacks
are alleviated but disturbing emotional or behavioral
difficulties persist, the addition of tranquilizing
drugs may help.

Phenothiazine can be employed to reduce fear,
hostility or sexual unrest, even though it lowers
seizure threshold and can produce seizures. In child-
hood behavior disorders, meprobamate or librium
combined with anticonvulsant drugs may be helpful.
Reserpine has also been successfully used in con-

junction with anticonvulsant drugs, especially in
patients with migraine-like headaches. In certain
cases stimulating drugs such as amphetamines, dex-
troamphetamine sulfate and caffeine may be indi-
cated to counteract the lethargic effects. Occasion-
ally in hyperkinetic children these drugs are of
value when anticonvulsants alone are not effective.

SURGICAL THERAPY

In cases where drug therapy fails and the electro-
encephalogram, possibly with pneumoencephalogra-
phic evidence, indicates a focal lesion of the tem-
poral lobe, surgical exploration and removal of the
area from which abnormal discharges occur should
be carried out. Drug therapy in smaller dosage will
have to be continued even after surgical removal of
focus, but usually with greater effectiveness in pre-
venting seizures. Operations of this kind are best
carried out in a clinic that has developed teamwork
between the neurosurgeon and the electroencepha-
lographer.

2000 Dwight Way. Berkeley 4.

REFERENCES

1. Aird, Robert B., and Tsubaki, Tadao: Common

sources of error in the diagnosis and treatment of convul-
sive disorders, J. Nerv. and Mental Dis., 127:400-406, No-
vember 1958.

2. Gibbs and Gibbs: Atlas of Electroencephalography,
Vol. 2, 1952. 168-171, Addison Wesley Press Inc., Cam-
bridge, Mass.

3. Sarvis, Mary A.: Psychiatric implications of temporal
lobe damage, Psycho. Analytic. Study of the Child, 15:454-
481, 1960.

4. Schwade, E. D., and Geiser, Sara G. : Severe behavior
disorder vyith abnormal electroencephalogram. Dis. Nerv.
Syst., 21:616-620, November 1960.

5. Thompson, G. N., Marinacci, A. A.: Alcoholism, Chas.
C. Thomas Co., Springfield, 111., 1956, 464-470.

VOL. 97, NO. 6 • DECEMBER 1962

349

Pulmonary Operations in Emphysematous Patients

IVAN A. MAY, M.D., Oakland

Pulmonary operations may greatly benefit emphy-
sematous patients of two categories — those with
complications of emphysema and those who have
co-existing disease requiring surgical treatment. (See
Table 1).

Emphysematous patients have low pulmonary re-
serve. An infection which interferes with an already
small amount of ventilation may be most significant,
for patients with emphysema have difficulty in rais-
ing secretions, and as secretions accumulate they
cause more interference with ventilation and also
prevent healing of the infection. Respiratory acidosis
and coma may result although physical examination
and x-ray films may give little indication of so large
an accumulation. In some instances, tracheal suction,
bronchoscopy and especially early tracheostomy
may be lifesaving.

Localized bullae may become infected and re-
quire drainage. Open or closed methods may be
necessary if they cannot be adequately drained
through the bronchial tree. Resection may be neces-
sary in order to eliminate the infection or the site
of a possible recurring infection.

Bronchiectasis in a portion of the lung of an em-
physematous patient may cause recurring infection.
Resection of the bronchiectatic segments may greatly
help the patient.

Localized bullae sometimes progress to large size
and interfere with ventilation by occupying space
and compressing functioning lung. These should be
removed. Occasionally a bulla may become a ten-
sion cyst due to air-trapping and cause an acute
emergency. If the patient is in poor condition, plac-
ing a Monaldi drainage tube may be helpful. Suc-
tion over a long period may cause scarring and
clinical obliteration of the cyst.1

Since emphysematous patients have little pul-
monary reserve, spontaneous pneumothorax may be
a very dangerous lesion. The lung tends to continue
leaking because of poor structure. Tension pneumo-
thorax is more likely due to air-trapping mechanism.
Prompt thoracostomy and placement of a large tube
is indicated. This is normally done in the patient’s
hospital room, using local anesthesia. A Trochar is
not used because of the large size required (No. 40
Malecot). Thoracentesis is unsafe because of the
lack of respiratory reserve, the tendency to continue

Submitted August 1, 1962.

• Although emphysema itself is a disease of the
entire lungs and so is not amenable to surgical
therapy, there are many conditions in emphyse-
matous patients in which surgical operation can
be quite helpful — for example, some complica-
tions of emphysema and some conditions not
etiologically related to emphysema but affecting
the lungs. Among these conditions are infectious
diseases (pneumonia, bronchiectasis, tuberculosis
and infected bullae) and other conditions such
as spontaneous pneumothorax, the presence of
space-occupying bullae and carcinoma.

The surgical treatment required may range
from suction or drainage to wide resection.

TABLE 1. — Summary of Indications for Pulmonary Operations on
Emphysematous Patients

Operation

Generalized emphysema None generally accepted

Surgical lesions

Complications of emphysema:

Infection :

Pneumonia (no reserve) . .Tracheal suction
Bronchoscopy
Tracheostomy

Infected bullae Drainage (open or closed)

Resection

Bronchiectasis

(focal infection) Resection

Localized bullae

(space occupying) Resection,2 Monaldi1

Spontaneous pneumothorax... Thoracentesis

(rarely, if ever)

Tube thoracostomy
Resection of bullae

Coexisting lung disease

Carcinoma or tuberculosis Resection with lung

conservation
Adjunctive measures

leaking air and the possibility of needle injury to
an easily damaged emphysematous lung. Tube thora-
costomy rapidly expands the lung and keeps it ex-
panded so long as the tube functions satisfactorily.
Use of more than one tube, and replacing or relocat-
ing blocked tubes, may be required. When the lung
cannot be expanded by tubes, thoracotomy is indi-
cated for resection of bullae, for freeing of adhe-
sions to allow the lung to expand evenly and fill the
thorax, and for suturing of major leaks.

Emphysematous patients may have co-existing
lung disease such as carcinoma or tuberculosis. Re-
section of the lesion with conservation of as much

350

CALIFORNIA MEDICINE

of the lung as possible, should be carried out if cir-
cumstances permit. Bronchoplasty may help preserve
necessary lung.

When operation is indicated in an emphysematous
patient, supportive measures such as tracheal suc-
tion, bronchoscopy, and particularly tracheostomy,
are often required to obtain adequate bronchial toi-
let. Pneumoperitoneum may also be of value to ele-
vate the diaphragm, diminish the size of the thoracic
cavity and help the lung fill the thorax. When the

lung is expanded against the chest wall it will adhere
at the point of air leaks and seal them.

3115 Webster Street, Oakland 9-

REFERENCES

1. Head, J. R., and Avery, E. E.: Intracavitary suction
(Monaldi) in the treatment of emphysematous bullae and
blebs, J. Thor. Surg., 18:761-776, 1949.

2. Stone, D. J., Schwartz, A., and Feltman, J. A.: Bullous
emphysema — a long-term study of the natural history and
the effects of therapy, Am. Rev. of Resp. Dis., 82:493-507,
1960.

The Myeloproliferative Disorders

Current Clinical and Laboratory Considerations

JORGE A. FRANCO, M.D., San Jose

According to currently favored views,4 in the
bone marrow the primitive mesenchymal cell dif-
ferentiates along the hemopoietic line as well as
along the connective tissue series (fibrocytes, osteo-
cytes, lipocytes).

Under physiologic conditions there is an orderly
proliferation of the hemopoietic derivatives of the
mesenchymal cell (granulocytes, erythrocytes, mono-
cytes and megakaryocytes and platelets). This pro-
liferation is matched by controlled removal of the
mature end products of the respective cell lines,
resulting in a fairly narrow range of normality.
Similarly, the proliferation of connective tissue cells
is kept within physiologic limits.

Clinical and experimental observations have
demonstrated in some situations a selective pro-
liferative response of a single blood cell line to
a single stimulus, while in other instances a single
stimulus seems to elicit a total hemopoietic re-
sponse.

Examples of the first type of single cell response
are the polycythemia of high altitude9 (secondary
to decreased oxygen saturation of arterial blood),
and the neutrophilia that follows injections of
bacterial polysaccharides.2

Examples of a total hemopoietic proliferative re-
sponse to a single stimulus are met in the pancytosis
induced in animals by the injection of the heat-
stable fraction of polycythemic plasma and the ad-
ministration of betyl alcohol.7,8

In all the above situations, the removal of the
stimuli (return to sea level in the cases of poly-
cythemia of high altitude, discontinuance of the
administration of bacterial polysacchrarides and
betyl alcohol) is constantly followed by a return of
all the different blood cells to physiologic values.

A different situation occurs when the stimuli re-
main unknown, and the myeloproliferation ulti-
mately ends fatally.

We therefore distinguish two basic types of myelo-
proliferation : reactive and neoplastic.

In the study of both the reactive and neoplastic
types of myeloproliferation, correlation of the clini-
cal manifestations with conditions observed on

Submitted July 20, 1962.

• The various hemopoietic and supportive cells
of the marrow may proliferate beyond physio-
logic boundaries in response to a number of
stimuli.

In certain instances, the stimuli are known,
and upon their removal the myeloproliferation
returns to normal boundaries. These, the reac-
tive myeloproliferations, are best represented by
the leukemoid states and the secondary poly-
cythemias.

In other cases, the stimuli responsible for the
myeloproliferation remain unknown and the
clinical disease ends fatally. These, the neoplas-
tic myeloproliferations, include the granulocytic,
monocytic and red cell leukemias, as well as the
polycythemia vera and myelofibrosis syndrome.

In clinical practice it is important to identify
the various myeloproliferative syndromes. This
task has been facilitated by cytochemical tests
that have recently become available, among
which the estimation of the leukocyte alkaline
phosphatase (LAP) in peripheral blood is a
technically simple and extremely useful example.

The LAP is normal in secondary polycythemias
and decidedly elevated in polycythemia vera,
myelofibrosis and leukemoid states. It is greatly
decreased in the granulocytic leukemias.

morphologic and cytochemical examination of speci-
mens of blood and bone marrow, permits establish-
ment of the proper diagnosis in most instances.
Among the cytochemical tests, the most useful is
the estimation of the alkaline phosphatase activity in
the leukocytes of the peripheral blood.

The Leukocytic Alkaline Phosphatase (LAP)3>5>6

Alkaline phosphatases are enzymes which at an
alkaline pH liberate orthophosphoric acid from a
number of alcoholic or phenolic monoesters. The
cytochemical demonstration of phosphatase activity
depends on the formation of an insoluble precipi-
tate at the site where the substrate hydrolysis has
occurred. This precipitate must have a color different
from the background and the cell cytoplasm. In the
most widely used method,6 the substrate is sodium-
alpha-naphtol-acid phosphate in a propanedial buf-
fer. The dye, Fast Blue RR, gives the precipitate
a dark brownish color.

Under physiologic conditions a number of mature
circulating granulocytes exhibit alkaline phospha-

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CALIFORNIA MEDICINE

tase activity. This activity can be expressed semi-
quantitatively by means of a “score.” Each cell is
rated from 0 (no activity) to 4+ (solid brown
cytoplasm). The possible range is 0-400. Normal
values in 100 consecutive determinations at O’Con-
nor Hospital, San Jose, were in general agreement
with data reported by other observers — that is,
normal range 20 to 48.

Reactive myeloproliferations

The reactive myeloproliferations are best repre-
sented by the myelocytic leukemoid reactions and
the secondary polycythemias.

The leukemoid state. In association with severe
bleeding, infection or neoplasia the number of
leukocytes may become greatly elevated (greater
than 50,000 per cu. mm.). Most of the leukocytes
are mature granulocytes, although with a variable
number of immature forms; toxic granulations may
occur; basophiles and eosinophiles disappear from
the peripheral blood. The bone marrow shows
granulocytic hyperplasia with moderate increase in
immature granulocytes. There is striking elevation
of the LAP in peripheral blood. This is a decisive
finding which differentiates the leukemoid reaction
from the granulocytic leukemias.

The secondary polycythemias. The cause may be
clinically evident (pulmonary disease, cyanotic
heart disease, androgen administration) or it may
require extensive investigation (brain tumor, renal
cell carcinoma, adrenal tumor, etc.). In peripheral
blood there is striking elevation of hemoglobin,
hematocrit and red cell values to polycythemic
levels. The granulocytes and platelets, however, re-
main quantitatively and qualitatively normal. The
bone marrow shows erythrocytic hyperplasia. The
LAP in peripheral blood is not elevated. This de-
cisive finding characterizes the secondary or reac-
tive form of polycythemia.

THE NEOPLASTIC MYELOPROLIFERATIONS

The neoplastic myeloproliferations may involve a
single cell line or may involve several cell lines
either successively or simultaneously. Among the
“pure” neoplastic myeloproliferations we include
the granulocytic and monocytic (Schilling type)
leukemias. Transitional forms do, however, occur.
The mixed myeloproliferations include polycy-
themia vera, myelomonocytic leukemias, myelo-
fibrosis syndrome and the erythemic myeloses. These
various syndromes will be reviewed from a clinical
and hematological point of view in decreasing order
of frequency as observed at O’Connor Hospital.

Chronic granulocytic leukemia. Splenomegaly is
the outstanding symptom-sign. The number of leuko-
cytes is decidedly elevated. Basophiles and eosino-

Characteristic Leukocyte Alkaline Phosphatase Content of
Peripheral Blood in Myeloproliferative Disorders

Decreased Normal Increased

Chronic granulocytic leukemia..

Acute granulocytic leukemia

Secondary polycythemia

Polycythemia vera

Leukomoid reaction

Myelofibrosis syndrome

philes may be numerous. There are moderate num-
bers of immature granulocytes and rare blast forms
in peripheral blood. Anemia is variable. The number
of platelets is usually elevated. There is granulo-
cytic hyperplasia of the marrow with increase in
immature granulocytes. The LAP in peripheral blood
is absent or considerably decreased. Even after ap-
parent remission following therapy, the LAP remains
abnormally low. It has been reported5 that in the
rare cases in which the phosphatase level returns
to normal the remissions are unusually long, which
would indicate a relative prognostic significance
of the test.

Acute granulocytic leukemia. There is anemia,
thrombocytopenia, presence of nucleated red cells
in peripheral blood and either leukopenia or leuko-
cytosis with the presence of blast forms. The bone
marrow is infiltrated by myeloblasts. The LAP in
peripheral blood is decidedly decreased. The clinical
symptoms (pallor, infections, hemorrhages) are an
expression of the hematologic abnormalities.

Polycythemia vera. In the initial, erythremic
phase, the classical clinical features are ruddy
cyanosis, splenomegaly, hepatomegaly and throm-
botic phenomena. In this stage the peripheral blood
shows pancytosis, with erythrocytes numbering
more than 7,000,000 per cu. mm. of blood, and
hemoglobin values of 18 to 24 gm. per 100 cc.
Leukocytes number between 15,000 and 40,000 per
cu. mm. with a few immature granulocytes and a
pronounced increase in platelets. The bone marrow
exhibits granulocytic and erythrocytic hyperplasia.
There is striking elevation of the LAP in peripheral
blood.

After a number of years, as the erythremic phase
of the disease wears out, the leukoerythroblastic
phase ensues. The splenomegaly becomes more
prominent. There is a return of hemoglobin con-
tent and red cell count to normal values, but the
leukocytosis and thrombocytosis persist and num-
bers of nucleated red cells and immature granulo-
cytes become conspicuous in peripheral blood. The
bone marrow is variously cellular. The LAP may re-
vert to normal values.

After additional years the final phase ensues and
the features of granulocytic leukemia (chronic or
acute) or those of myelofibrosis will occur.

VOL. 97, NO. 6 • DECEMBER 1962

353

Myelofibrosis syndrome (agnogenic myeloid
metaplasia of the spleen, etc.). Splenomegaly and
hepatomegaly are the outstanding signs. Peripheral
blood examination reveals anemia, reticulocytosis,
tear-shaped and comma-shaped erythrocytes, nu-
cleated red cells, giant platelets, thrombocytosis and
moderate increase in leukocytes with moderate
numbers of immature granulocytes. Often bone mar-
row aspiration is unsuccessful (dry taps). Surgically
excised specimens of marrow in well-established
cases reveals fibrosis and hypocellularity. Usually,
hut not constantly, there is pronounced elevation of
the LAP in peripheral blood.

In early cases, repeated marrow aspirations from
different sites may yield a cellular marrow. At the
same time, the enlarged liver and spleen are the
site of active extramedullary blood formation, as
demonstrated by biopsy studies. The current in-
terpretation of these findings is that the enlarge-
ment of liver and spleen with extramedullary hemo-
poiesis is not necessarily a compensatory mechanism
due to relative bone marrow failure, but that in
this syndrome the proliferative stimulus is potent
enough to induce hyperplasia of hemopoietic and
fibroblastic cells in the marrow as well as in organs
which are potentially hemopoietic (liver and spleen) .

In some cases the splenomegaly is associated with
hypersplenism. In such cases, according to recent
reports1 splenectomy may be beneficial in decreas-
ing the severity of the anemia.

In rare cases the outstanding hematologic ab-
normality in myelofibrosis is thrombocytosis. These
cases are placed in a separate category by a num-
ber of investigators.3

The monocytic leukemias. Swollen, tender gums
are the outstanding feature of the monocytic leu-
kemias. In the more common, myelomonocytic
leukemia (Naegli’s type), the peripheral blood
shows a mixture of immature granulocytes and
monocytes. Similar conditions are found in the bone
marrow. The lap in peripheral blood is at low
leukemic levels.

In pure monocytic leukemia (Schilling’s type) the
predominating cell in peripheral blood is a bizarre,
abnormal monocyte. Rare normal mature granu-
locytes can be seen in peripheral blood. The marrow
is predominatingly monoblastic-monocytic. The LAP
in peripheral blood in the few remaining gran-
ulocytes is within normal limits.

Red cell leukemias (Di Guglielmo’s syndrome) .
The severity of the hematological changes parallels
the clinical course (acute, subacute or chronic).
Anemia, leukopenia and thrombocytopenia are fea-
tures. Bizarre and immature nucleated red cells are
conspicuous in peripheral blood. The bone marrow
is infiltrated by bizarre erythroblasts (megalo-
blasts) and myeloblasts. The unique feature that
the red cell precursors are rich in glycogen helps to
identify the disorder. The LAP in peripheral blood
is decreased.

O'Connor Hospital, Forest and De Salvo Streets, San Jose 28.

REFERENCES

1. Buroncle, B. and Doan, Charles: Myelofibrosis: Clini-
cal, hematologic and pathologic study of 110 patients. Am.
J. Med. Sc., 243:697, June 1962.

2. Craddock, C.: Production and Distribution of Granu-
locytes and the Control of Granulocyte Release in Hemo-
poiesis (Ciba Foundation Symposium), Boston 1960, Little,
Brown & Co.

3. Dameshek, W. and Gunz, F. W. : Leukemia. New York,

1958, Grune & Stratton.

4. Downey, H. : Handbook of Hematology, New York,
1938, Paul B. Hoeber, Inc.

5. Hayhoe, F. G. and Quaglino, D.: Cytochemical demon-
stration and measurement of leucocytic alkaline phosphatase
activity in normal and pathological states by a modified
azo-dye coupling technique. Brit. J. Haemet., 4:375, 1958.

6. Kaplow, L. S. : A hystochemical procedure for localiz-
ing and evaluating leucocytic alkaline phosphatase in smears
of blood and bone marrow. Blood, 10:1023, Oct. 1955.

7. Linman, J. W., Long, M. J., Korst, D. R. and Bethell,
F. H.: Studies on stimulation of hemopoiesis by betyl
alcohol. J. Lab. Clin. Med., 54:335, Sept. 1959.

8. Linman, J. W., Bethell, F. H. and Long, M. J.: Factors
controlling hemopoiesis: Experimental observations on their
role in polycythemia vera. Ann. Int. Med., 51:1003, Nov.

1959.

9. Merino, C. : Studies on blood formation and destruction
in the polycythemia of high altitude. Blood, 5::1, Jan. 1950.

354

CALIFORNIA MEDICINE

CASE REPORTS

Papillary Carcinoma of the Renal Pelvis
Following Cystectomy and Bricker
Procedure for Carcinoma of the Bladder

JERRY B. MILLER, M.O., and

JOSEPH J. KAUFMAN, M.D., Los Angeles

That urothelial tumors are multicentric is basic
urological knowledge. Whether they are multicen-
tric at the outset or become so by implantation is
yet to be resolved; there is evidence to support both
theories.3,7 As the antegrade dissemination of uro-
thelial tumors is well recognized, primary papillary
tumors of the renal pelvis and ureter must be treated
by total nephroureterectomy, including dissection
of a cuff of bladder in order to minimize the inci-
dence of papillary tumor at this site. However, the

From the Department of Surgery (Urology), University of Cali-
fornia Medical Center, Los Angeles 24, California, and the Wads-
worth General Hospital, Veterans Administration Center, Los An-
geles 25.

Presented before the Section on Urology at the 91st Annual Ses-
sion of the California Medical Association, San Francisco, April 1 5
to 18. 1962.

retrograde dissemination of tumor is a subject of
somewhat more speculative interest. It is obvious
that if one supports the implantation theory, vesi-
coureteral reflux will cause ureteral or pelvic tu-
mors to be implanted from bladder tumors.

We are reporting herein two cases of papillary
tumor of the renal pelvis which occurred after total
cystectomy for transitional cell carcinoma of the
bladder and ureteroileocutaneous urinary diversion.
We believe that these cases are of special interest
because the Bricker procedure provides for optimum
drainage of urine with no reservoir to allow pressure
and reflux. Furthermore, the tumors appeared to
arise in the pelvis rather than by direct extension
up the ureter from the area of anastomosis. These
factors would seem to substantiate, at least in these
cases, the theory of multicentricity rather than im-
plantation by reflux. The latter might occur in cases
of ileal or colonic reservoirs where intraluminal
pressure and reflux favor the implantation of tumors
in a retrograde manner.

Figure 1. — (Case 1). — Left, normal intravenous pyelogram, March 20, 1959. Right, filling defect in pelvis of right
kidney, suggesting renal papillary tumor. May 15, 1961.

VOL. 97, NO. 6 • DECEMBER 1962

355

Figure 2. — (Case 1)- — Ileostogram showing reflux up
the left ureter revealing a normal left collecting system,
but complete blockage on the right.

REPORTS OF CASES

Case 1. The patient, a 53-year-old man, had had
transurethral resection of a transitional cell carci-
noma of the bladder (grade II) six months before
admission to hospital in March 1959. Cystoscopic

and bimanual examinations immediately before ad-
mission revealed multiple exophytic tumors with no
fixation of the bladder. Therefore, total cystectomy
and bilateral ureteroileal anastomosis with cutane-
ous ileostomy was carried out on March 9, 1959.
The preoperative intravenous urogram showed nor-
mal upper urinary tract architecture bilaterally with
no evidence of ureteropelvic filling defects.

After the operation, electrolyte and creatinine de-
terminations remained within normal limits. With
the exception of one episode of pyelonephritis
characterized by chills and fever and responding
promptly to sulfonamide therapy, the patient re-
mained well until in May of 1961 he noticed blood
in the urine. There was no pain associated with
the gross hematuria or with the passage of clots.
Whereas intravenous urograms on March 20, 1959,
were normal, a pyelogram on May 15, 1961, showed
filling defects in the pelvis of the right kidney and
suggested papillary pelvic tumor (Figure 1). Papa-
nicolaou study of the urine showed class II atypical
cells, not suggestive of malignant disease. On May
24 the patient had severe right flank pain and gross
hematuria. At this time an intravenous urogram
showed no appearance of dye in the right kidney,
and an ileostogram showed prompt reflux on the
left, outlining a normal ureter, pelvis and calyces,
but showed no reflux up the right ureter (Figure 2) .
On May 26, because of complete right renal block-
ade associated with fever, the right kidney was ex-
amined through a flank incision and radical ne-
phrectomy and ureterectomy were carried out. There
were lymph nodes in the renal hilar area and along

vis*-

v*.

' V5*-;

• •5 '.4

* V
>

Figure 3. — (Case 1) — Left, photomicrograph (X250) showing papillary transitional cell carcinoma of the uri-
nary bladder. Right, (X250) showing papillary transitional cell carcinoma of the renal pelvis. The slides are shown
side by side to demonstrate the same type of tumor cell present in bladder and renal pelvis.

356

CALIFORNIA MEDICINE

the vena cava which were grossly involved by tu-
mor. The ureter was removed flush with the ileum.

The postoperative course was uneventful and the
patient was discharged on the eighth postoperative
day. The pathologist reported transitional cell carci-
noma of the inferior calyx of the right kidney with
extension to the ureter (Figure 3). Metastatic tran-
sitional cell carcinoma was found in one of four
hilar lymph nodes. The kidney showed chronic and
acute pyelonephritis and the ureter chronic and
acute ureteritis with ureteritis cystica.

The patient thereafter was examined regularly in
the outpatient department. The gross renal function
and electrolytes always were within normal limits,
as was an intravenous urogram shortly before the
time of this report. Although the patient has sur-
vived one year since right nephrectomy, the prog-
nosis is obviously poor.

Case 2. A 70-year-old white man was admitted to
the Veterans Administration Hospital in Los An-
geles on April 25, 1957, because of obstructive uri-
nary symptoms. He was found to have moderate
prostatic enlargement and a fungating lesion on the
floor of the bladder. Blood creatinine was within
normal limits and no abnormalities were seen in
roentgen examination of the chest and bones. An
intravenous urogram disclosed a duplex collecting
system on the right with ureteral duplication down
to the bladder. On the left, there was a single col-
lecting system (Figure 4). Neither side showed fill-
ing defects in the hollow portion.

The bladder tumor was removed by transurethral
resection and the pathologist reported grade II tran-
sitional cell carcinoma with no evidence of muscle
invasion. Two weeks later, transurethral resection
of the prostate was done.

In July 1957, transurethral resection of a recur-
rent bladder tumor was done. The diagnosis was
transitional cell carcinoma grade II of the urinary
bladder. Another recurrence in November 1957 was
treated by transurethral resection. In 1958, cystos-
copy showed an extensive bladder tumor about the
left ureteral orifice. On this occasion, biopsies
showed transitional cell carcinoma, grade II to III.
No mass was felt on bimanual examination. Because
of the progressive frequency and size of the recur-
rences, cystectomy and ureteroileal anastomosis with
ilealcutaneous conduit were done.

The surgeon failed to bring one of the ureters on
the right (the duplication) into the anastomosis
and the patient developed retroperitoneal urinary
extravasation with pelvic and retroperitoneal ab-
scesses. Another operation was carried out to join
the second right ureter to the ileal conduit. After a
stormy postoperative course, during which time the
body weight dropped from 124 pounds to 69, the
patient gradually began to regain strength, and was
gaining weight when he was discharged. The pathol-
ogist reported papillary transitional cell carcinoma
of the urinary bladder (Figure 5). Six lymph nodes
were negative for tumor. Occasional postoperative

Figure 4. — (Case 2) — Normal intravenous pyelogram
taken in December of 1957. Note right-side duplication
radiologically complete.

Figure 5.— (Case 2) — Photomicrograph ( X 250 ) of pap-
illary transitional cell carcinoma from the urinary bladder.

intravenous urograms showed good appearance of
the upper tracts until December of 1959, at which
time there was a suggestion of a filling defect in the
left renal pelvis.

On April 27, 1961, an intravenous urogram (Fig-
ure 6) showed an unquestionable filling defect in
the left renal pelvis and upper ureter, and a clinical
diagnosis of papillary tumor of the left renal pelvis
was made. Left radical nephrectomy was performed
to remove the left ureter at its juncture with the
ileal conduit. There was gross tumor extension to

VOL. 97, NO. 6 • DECEMBER 1962

357

Figure 6. — (Case 2) — Intravenous pyelogram on April
27, 1961, showing an unquestionable filling defect in the
left renal pelvis and left ureter. A diagnosis of papillary
tumor of the left renal pelvis was made following this
film.

the hilar and periaortic lymph nodes. After the op-
eration the patient gained weight to the preoperative
level of approximately 110 pounds. Tissue examina-
tion of the kidney showed infiltrating transitional
cell carcinoma, grade IV, extending from the renal
pelvis down the ureter (Figure 7) . Two lymph nodes
showed diffuse tumor metastasis (Figure 8). It was
decided to give no irradiation therapy postopera-
tively. At last report, eight months following left
nephrectomy, the patient’s weight was being main-
tained at 105 to 110 pounds and he had no com-
plaints. However, the outlook was considered dismal.

DISCUSSION

The prognosis of papillary tumors of the renal
pelvis and ureter has been spectacularly improved
by application of complete nephroureterectomy.
This was emphasized by O’Connor.8 Kaminsky also
stressed that the tendency of pelvic ureteral tumors
to spread by reimplantation dictates nephroureterec-
tomy.5 He also posed a question as to whether
spread is direct or by lymphatic channel. Probably
in our cases, lymphatic spread would be the most
likely, for two reasons. First, the lymphatic pathway
is from the bladder to the area of tbe renal pelvis.
Second, in both cases the lymph nodes were in-
volved with tumor.

Garcia and Bradfield2 reported a case of bilateral

Figure 7. — (Case 2) — Photomicrograph (X250) of in-
filtrating transitional cell carcinoma of the renal pelvis.
This tumor also extended down the ureter.

Figure 8. — (Case 2) — Photomicrograph (X250) of
lymph node showing tumorous involvement. Same type
of tumor in lymph node as in renal pelvis. Exactly same
type of tumor present in Figures 5, 7, and 8.

358

CALIFORNIA MEDICINE

simultaneous primary carcinoma of the ureter. They
cited Felber,1 who reported an asynchronous bilat-
eral benign papilloma of the ureter with subsequent
cancer of the ureteral stump, bladder and vagina.
They also mentioned Ratliff,9 who reported a case
of primary bilateral carcinoma of the ureter. Evi-
dence that carcinogenic agents in the urine produce
urothelial papillary tumors is, of course, now rather
substantial.4

Riches and Page10 reported a case in which a car-
cinoma developed in the sigmoid colon following
cystectomy and ureterosigmoidostomy for carcinoma
of the bladder. They thought that this was the first
case of this type to be reported.

Hueper and coworkers4 were able to produce
bladder tumors in dogs by feeding them B-naphthyl-
amine, but could not produce these tumors in the
colon when the urine had been diverted into an iso-
lated sigmoid loop. They suggested that the secre-
tion from the mucous glands prevented contact of
the carcinogenic agent with the epithelium or in
some way counteracted or destroyed its effective-
ness.4

Lewis,0 in a discussion of a paper by Kerr and
Colby, cited the case of a patient with total cystec-
tomy who had had no evidence of a lesion of either
ureter before operation but died of a new growth
of a grade II tumor in the ureter, 4 inches above
the site of a ureterosigmoidostomy, three and a half
years after operation. Lewis expressed belief that
since we cannot eradicate the cause of the cancer
or eliminate the source tissue, treatment must be
adequate to remove the local lesion and, when indi-
cated. the lymphatic drainage tracts. In his opinion
lymph node dissection should be part of the pro-
cedure of total cystectomy.

SUMMARY

Two cases of carcinoma of the renal pelvis after
cystectomy for carcinoma of the bladder, the first
in the literature, are reported. The delayed appear-
ance of these tumors suggested lymphatic spread
rather than direct extension. De novo origin of these
tumors cannot be excluded although this theory
(multicentric origin) seems less likely to us than
that of lymphatic spread.

Department of Surgery/Urology, UCLA Medical Center, Los An-
geles 24 ( Miller) .

REFERENCES

1. Felber, E. : Asynchronous bilateral benign papilloma of
the ureter with subsequent cancer of the ureteral stump,
bladder, and vagina, J.M.A. Georgia, 42:198, 1953.

2. Garcia, V., and Bradfield, E. 0.: Simultaneous bilateral
transitional cell carcinoma of the ureter: A case report,
J. Urol., 79:925, 1958.

3. Hinman, F., Jr.: The recurrence of bladder tumors,
J. Urol., 83:294, 1960.

4. Hueper, W. C., Wiley, F. H., and Wolfe, H. D.: Ex-
perimental production of bladder tumors in dogs by admin-
istration of beta-naphthylamine, J. Industrial Hygiene,
20:48, 1938.

5. Kaminsky, A. F. : Associated kidney and bladder tu-
mors, J. Urol., 61:997, 1949.

6. Lewis, L.: In Discussion of: Kerr, W. S., Jr., and
Colby, F. H.: Carcinoma of the bladder: A correlation of
pathology with treatment and prognosis, (in discussion),
J. Urol., 65:841, 1951.

7. Melicow, M. M.: Tumors of the urinary bladder: A
clinicopathological analysis of over 2,500 specimens and
biopsies, J. Urol., 74:498, 1955.

8. O’Connor, V. J.: The treatment and prognosis of papil-
lary tumors of the renal pelvis and ureter, J. Urol., 61:488,
1949.

9. Ratliff, R. K., Baum, W. C„ and Butler, W. J.: Bi-
lateral primary cancer of the ureter: A case report, Cancer,
2:815, 1949.

10. Riches, E. W., and Page, R. H. : Transitional cell car-
cinoma of the colon following cystectomy and uretero-sig-
moidostomy for carcinoma of the bladder, Brit. J. Urol.,
28:288, 1956.

Acute Radiation Nephritis

JOHN N. BALDWIN, M.D., San Francisco, and
JACK W. C. HAGSTROM, M.D., New York

With the multitude of beneficial uses made pos-
sible in the present era of high-energy x-ray tech-
niques, the recognition of side effects and hazards
assumes new importance. In this regard, the syn-
drome of radiation nephritis has not received wide-
spread attention.

As far back as 1927, American investigators5
demonstrated the production of renal insufficiency
in dogs following deep irradiation, and described
the interstitial fibrosis, tubular atrophy and glo-
merular hyalinization which characterize radiation
nephritis. They stated, contrary to widespread opin-
ion then prevalent, that the kidney was quite sus-
ceptible to the effects of x-ray.

Shortly afterward, Domagk4 reported the first
fatal case of radiation nephritis, in a nine-year-old
girl who had received x-irradiation to the abdomen
for mesenteric lymphadenitis. He described the pre-
senting symptoms of anemia, albuminuria and a
progressive downhill course terminating in renal
failure six months following the therapy. Recently,
Redd10 added one more case of nephritis to the re-
ported series, bringing the total to 64. The patient
he described had carcinoma of the ovary and, fol-
lowing the administration of a 4,200 r mid-plane
dose over a period of 47 days, developed hyperten-
sion, anemia, albuminuria, azotemia and cardio-
renal failure.

Despite this documentation, cases continue to ap-
pear, and for this reason the case below is presented.

REPORT OF A CASE

A 63-year-old white man entered The New York
Hospital for the first time in August, 1959, with

From the Department of Surgery, University of California Medical
Center, San Francisco (Baldwin), and the Department of Pathology,
The New York Hospital-Cornell Medical Center (Hagstrom).

Submitted April 13, 1962.

VOL. 97, NO. 6 • DECEMBER 1962

359

complaint of abdominal fullness and a 12-pound
loss of weight. He was otherwise well. He was well-
developed and healthy-appearing. The blood pres-
sure was 130/70 mm. of mercury. A hard, irregular
mass was felt in the left upper quadrant of the ab-
domen. The hematocrit was 40 per cent and the
hemoglobin content was 12.5 gm. per 100 ml. The
blood urea nitrogen was 13 mg. per 100 ml. Results
of urinalysis were within normal limits. Roentgen
study of the upper gastrointestinal tract showed
a large filling defect of the proximal one-third and
body of the stomach. At exploratory laparotomy a
lymphosarcoma, 10 cm. in diameter, was found in-
vading the major branches of the aorta in this area.
The tumor was not resectable.

On September 1, 1959, a 39-day course of x-ray
therapy was begun, directed through two anterior
and two posterior truncal ports. The calculated tu-
mor dose was 3,870 r; the calculated dose to each
kidney was 3,960 r. After this treatment the patient
was symptom-free for five and a half months. Then
in April, 1960, he noted weakness, shortness of
breath and the onset of moderately severe head-
aches.

On May 18 he was admitted for the second time
with acute pulmonary edema. He was pale and in
severe respiratory distress. The blood pressure was
230/120 mm., the pulse rate 126 and respirations
30 per minute. Moist rales were heard in the apices.
The heart was enlarged and a protodiastolic gallop
was heard at the apex. Pitting sacral and pre-tibial
edema was noted.

The hematocrit was 23 per cent. Hemoglobin con-
tent was 7.5 grams per 100 ml. and erythrocytes
numbered 2,500,000 per cu. mm. The platelets were
adequate and the red blood cells were normochromic
and normocytic. The blood urea nitrogen was 68
mg. per 100 ml. Specific gravity of the urine was
1.014 and the albumin reaction was 4 plus. There
were five to fifteen red cells and many coarse granu-
lar casts per highpower field. In an x-ray film of
the chest, diffuse enlargement of the heart, pulmo-
nary vascular congestion and left pleural effusion
were noted.

The patient was treated for pulmonary edema.
Hydralazine, reserpine, morphine, meralluride and
digitoxin were administered. Packed-cells were
given cautiously. The response at first was good.
Nevertheless, the blood urea nitrogen rose, and by
the end of the first hospital week had reached 88
mg. per 100 ml. Because of persisting anemia, fre-
quent blood replacement was necessary. Albuminu-
ria and hypertension (blood pressure averaging
200/100 mm. of mercury) persisted and corticos-
teroids were used on a trial basis, although little
information existed concerning their efficacy in this
syndrome.6 Prednisone (40 mg. per day) was be-
gun and continued for two weeks. During this
period there was no improvement. Hypertension
persisted and was resistant to all therapy.

Figure 1. — Glomeruli show an advanced degree of
sclerosis. There is increased interstitial fibrous tissue.
(X169. Hemotoxylin and eosin stain.)

Figure 2. — An arteriole showing intimal, endothelial
proliferation. There is increased interstitial fibrous tissue
with scattered foci of chronic inflammatory cells. (X169.
Hemotoxylin and eosin stain.)

Despite supportive and therapeutic management
the patient became uremic, oliguric and hypoten-
sive. He died eight weeks after admission and nine
months after radiotherapy.

Necropsy

There was radiation pigmentation over the ab-
domen. The kidneys together weighed 310 gm. The
capsules stripped with ease from the smooth sur-
faces. The cortico-medullary junctions were distinct.
The parenchyma offered increased resistance to cut-
ting. Microscopically, moderate numbers of glomer-
uli were partially or totally sclerotic (Figure 1),
and most of the remaining glomeruli had thickening,
reduplication and splintering of basement mem-
branes. Some glomeruli, which were seemingly
bloodless, had clubbing of capillary tufts. There was
a moderate increase in the interstitial fibrous tissue,
in which there were foci of chronic inflammatory
cells, hemosiderin-laden macrophages and focal
areas of hemorrhage. Walls of small arteries and
arterioles were thickened by hypocellular fibrous
tissue (Figure 2). No residual tumor was identified

360

CALIFORNIA MEDICINE

100

TIME IN MONTHS

Chart 1. — Direction of the several clinical courses that may follow radiation-induced renal damage.

in or around the stomach either grossly or micro-
scopically.

The final diagnosis : Irradiated lymphosarcoma of
the stomach and radiation nephritis.

DISCUSSION

Radiation nephritis may be thought of as a syn-
drome in which renal damage is brought about by
ionizing radiation and a clinical picture of cardio-
renal and hematopoietic failure develops after a
latent period of six months or more.

The clinical features of radiation nephritis vary
according to the amount, extent, duration and dis-
tribution of irradiation. In 1952, Kunkler7 studied
20 patients with renal damage following x-ray baths
for seminoma and pointed out that in all cases in
which renal failure developed, each whole kidney
had received 2,300 r or more in five weeks or less.
(The patient in the present case received an esti-
mated 3,960 r to each kidney in 39 days.) Kunkler
also stated that the amount of renal damage seen
histologically correlated well with the anatomical
distribution of the irradiation.

In the present case the latent period between
the completion of x-ray therapy and the develop-
ment of the first signs of renal damage was seven
months, which correlates well with the observations
of Domagk,4 Kunkler,7 Jernigan6 and Schreiner.11

During this period, renal damage proceeds on a
cellular basis until a stage is reached when there
are clinical manifestations of illness. Following the
relatively asymptomatic latent period, one of several
courses will follow (Chart 1). These have been out-
lined by Luxton9: (1) Acute radiation nephritis;
(2) chronic radiation nephritis; (3) benign hyper-
tension; (4) late malignant hypertension.

Acute radiation nephritis follows abdominal-
renal x-irradiation by a latent period averaging six
to 12 months. Early signs of development may be
headache (hypertension) , anorexia (azotemia) and
weakness (anemia). The onset of clinically mani-
fest disease is usually abrupt, with sudden conges-
tive heart failure, pulmonary edema and anasarca.

These symptoms stem from a failure of three in-
terrelated systems : renal, hematopoietic and cardiac.
Deterioration of kidney function probably occurs
first, with consequent loss of concentrating power,
nitrogen retention and albuminuria.1 Oliguria is a
terminal event, and death usually occurs within
three or four months of the appearance of symp-
toms.11 The anemia of acute radiation nephritis is
severe, rapid, refractory and normocytic-normo-
chromic. The marrow is not aplastic.7

Cardiac failure is often the presenting symptom
of acute radiation nephritis. Hypertension is strik-
ing and has been assumed to be secondary to renal
damage.8 Dean and Abels3 in 1944 described a

VOL. 97, NO. 6 • DECEMBER 1962

361

young normotensive woman who received 4,600 r
to the left renal area for intra-abdominal lympho-
sarcoma. Following a latent period of seven years,
her blood pressure was found to be 184/125 mm.
of mercury. Left nephrectomy was performed and in
the shrunken kidney pronounced glomerular sclero-
sis and intimal arteriolar thickening were noted.
After operation, the patient became normotensive.
Levitt and Oran8 in 1956 reported on a 33-year-old
man who had received 3,000 r to the left renal bed
for a metastatic seminoma. Eleven years later, his
blood pressure was 215/130 mm. of mercury. The
left kidney was removed and showed almost com-
plete obliteration of glomeruli and pronounced in-
terstitial fibrosis. The blood pressure returned to
normal.

Chronic radiation nephritis2 may be interpreted
as a less severe process, clinically and pathologically.
It usually follows a longer latent period — ten
months or more — is insidious in onset and pro-
tracted in duration. Mild hypertension, albuminuria,
anemia and azotemia are concomitant, but cardiac
decompensation and abrupt renal failure are infre-
quent. Jernigan6 outlined the course of chronic radi-
ation nephritis in a young woman who received a
3,000 r tumor dose for a right ovarian cystade-
noma. Nine months following treatment she began
to have headache, weakness and edema, and the
blood and urinary abnormalities of hematopoietic-
renal failure appeared. Renal biopsy showed inter-
stitial fibrosis and glomerular sclerosis. The patient
was sustained by supportive therapy through a near-
acute phase and the disease went on to a milder,
protracted course which was termed chronic.

Benign hypertension may also develop. It is asso-
ciated with mild (usually systolic) elevation of
blood pressure. Renal function remains normal and
there is only a trace of albuminuria. Luxton9 said
that a late malignant hypertension may develop as
long as 24 months after irradiation. Due to the
length of the latent period and the degree of malig-
nancy of the tumor necessitating irradiation, exam-
ples of this type are only occasionally seen.

Four structures are severely affected by renal
irradiation : interstitium, glomeruli, tubules and
arterioles. Most consistently there is fibrosis of the
interstitium; and, in time, contraction of the scar
tissue leads to interference with glomerular and
tubular blood supply. The glomeruli may be atro-
phied, have endothelial proliferation or show par-
tial or complete fibrosis. Tubules may undergo
necrosis and atrophy. Arteriolar walls are often
thickened and many show intimal endothelial pro-
liferation.

Care of the patient in any of the phases of ne-
phritis can only be supportive and symptomatic, as
there is no evidence to indicate that the lesions will
regress. In the case herein reported, a brief trial of
corticosteroids had no effect. The only other in-
stance in which the use of corticosteroids has been
cited is in the report by Jernigan6 of a patient who

survived and entered a chronic phase. More infor-
mation is necessary as to the efficacy of steroid
therapy.

It would seem superfluous to discuss the preven-
tion of this apparently avoidable process. However,
the existence of this case and others is justification
for emphasizing the importance of pre-irradiation
renal evaluation and of careful calculation of dosage
and port location to involve the kidneys as little as
possible. In most cases of patients needing radiation
therapy that incidentally impinges on the kidneys,
it seems ill-advised to administer more than 2,000 r
to either kidney. Follow-up observation of patients
who have had abdominal irradiation is important.

SUMMARY

A case of acute radiation nephritis in a 63-year-
old man is reported. The clinical features included
hypertension, albuminuria, anemia, azotemia, con-
gestive heart failure and edema. This syndrome will
probably develop following the delivery of 2,300 r
or more to each kidney in five weeks or less. The
average latent period between irradiation and onset
of overt illness is about six to twelve months. Patho-
logical changes include extensive interstitial fibrosis,
glomerular hyalinization and tubular atrophy. A
regimen directed at correction of renal, cardiac and
hematologic derangement is necessary in manage-
ment.

Department of Surgery, University of California Medical Center,
San Francisco 22 (Baldwin).

REFERENCES

1. Bolliger, A., and Earlam, M. S. S. : Experimental renal
disease produced by x-rays, Med. J. Australia, 1 :340, March
1930.

2. Cogan, S. R., and Ritter, I. I.: Radiation nephritis:
A clinicopathologic correlation of three surviving cases,
Am. J. Med., 24:530, April 1958.

3. Dean, A. L., and Abels, J. C. : Study by the newer
renal function tests of an unusual case of a hypertension
following irradiation of one kidney and the relief of the
patient by nephrectomy, J. Urol., 52:497, Dec. 1944.

4. Domagk, G.: Rontgenstrahlenschadigungen der Niere
beim Menschen, Med. Klin., 23:345, March 1927.

5. Hartman, F. W., Bolliger, A., and Doub, H. P. : Func-
tional studies throughout course of roentgen-ray nephritis in
dogs, J.A.M.A., 88:139, Jan. 15, 1927.

6. Jernigan, J. A.: Chronic radiation nephritis, Ann.
Intern. Med., 51:1084, Nov. 1959.

7. Kunkler, P. B., Farr, R. F., and Luxton, R. W.: Limit
of renal tolerance to x-rays, Brit. J. Radiol., 25:190, April
1952.

8. Levitt, W. M„ and Oram, S.: Irradiation-induced ma-
lignant hypertension cured by nephrectomy, Brit. Med. J.,
2:910, Oct. 1956.

9. Luxton, R. W.: Radiation nephritis, Quart. J. Med.,
22:215, April 1953.

10. Redd, B.: Radiation nephritis: Review, case report
and animal study, Am. J. Roentgenol., 83:106, Jan. 1960.

11. Schreiner, B. F., and Greendyke, R. M.: Radiation
nephritis, report of a fatal case, Am. J. Med., 26:146, Jan.
1959.

362

CALIFORNIA MEDICINE

Diabetes Mellifus — "Brittle" Features
Due to Cardiospasm

PHILLIP L. ROSSMAN, M.D., and
ELMER C. RIGBY, M.D., Los Angeles

The term “brittle diabetes” usually indicates
unrecognized insulin hypoglycemia followed by a
rebound hyperglycemic phase which, when treated
with an increase in insulin dosage, results in a
recurrence of the hypoglycemia-hyperglycemia cycle.
Repeated similar episodes eventually cause liver
deglycogenation and ketosis. Improvement occurs
with reduction in insulin dosage or adequate car-
bohydrate intake.

The “brittle status” is more likely to develop in
strictly regulated patients whose diabetic state fluc-
tuates from day to day. Other causes of unstable
diabetes are focal infection, endocrine imbalance,
negligence by the patient, obesity, malnutrition,
faulty absorption of insulin, undiagnosed high renal
threshold and variations in physical activity. It
occurs also in patients with liver disease such as
cirrhosis or hemochromatosis severe enough to
interfere with adequate glycogen storage and re-
lease.

Brittle diabetes due to malabsorption and poor
glycogen storage secondary to cardiospasm and
malnutrition is described in the following case
history.

REPORT OF A CASE

A 61-year-old Caucasian woman had had diabetes
mellitus for 16 years. The patient had always been
well and had maintained her weight at about 115
pounds. She had never been on a quantitative diet,
but took about 1500 calories daily (carbohydrate
about 170 gm., protein 80 gm. and fat 60 gm. ).

From 1949 to 1954 she injected 45 to 50 units
of protamine zinc insulin subcutaneously every
morning and almost continually had four-plus post-
prandial glycosuria. Attempts to make the urine
sugar free resulted in frequent hypoglycemic attacks.
During 1954-55 she took 50 units of NPH insulin
every morning and still had three to four plus
glycosuria interspersed with attacks of hypoglyce-
mia. Minor insulin reactions were controlled with
sugar in orange juice; major reactions required
intravenous glucose.

Over the next three years, globin and lente insul-
ins, carbutamide and split insulin administration
were tried. However, she continued in the brittle
state with wide swings from severe acidosis to con-
vulsive hypoglycemia. She had no gastrointestinal
symptoms at this time and the results of physical
examination were within normal limits.

In July 1959, as part of an examination to ex-
clude a pancreatic tumor, gastrointestinal x-ray

From the medical and surgical services, Saint John’s Hospital,
Santa Monica.

Submitted May 16, 1962.

studies showed dilatation of the esophagus to three
times normal size, with retention of barium. After
an intramuscular injection of atropine, infrequent
spurts of barium passed into the stomach. Other-
wise, this study and an x-ray series of the gall-
bladder were normal. No abnormalities were noted
in a blood cell count, serum cholesterol content, a
serologic test for syphilis, a bromsulphalein test and
an electrocardiogram.

Six months later the patient began to lose appe-
tite and to have difficulty in swallowing solid foods
and later liquids. Her weight decreased to 101
pounds. Esophagoscopy and forceful dilation of
the area constricted by cardioesophageal spasm
were performed. The improvement was minimal
and after four additional dilatations the patient
refused further instrumentation. Her weight declined
to 93 pounds. On July 18, 1960, transthoracic gas-
troesophageal longitudinal myotomy extending from
the upper portion of the gastric fundus superiorly
for 8 cm. along the esophagus was carried out. The
hypertrophied circular muscles of the distal esopha-
gus were incised on the left posterolateral aspect.
The left vagus nerve was divided and a hiatal
hernia was also repaired.

The postoperative course was without complica-
tion. The patient was soon back to her 1,500-calorie
diet and was given protamine zinc insulin, 15 units
subcutaneously, and tolbutamide (Orinase®) 0.5
gm., orally, every morning. Her weight rapidly in-
creased to 115 pounds and no further nausea or
vomiting occurred. An x-ray film of the esophagus
13 months after operation showed no cardioesopha-
geal stricture. In the spring of 1961 the patient went
on a tour of Europe for six weeks and had no
problems in reference to diabetes. At last report, 27
months after operation, the patient was still well
and had had no attacks of diabetic coma or insulin
shock.

COMMENT

In the present case a starvation status developed
secondary to cardiospasm which was initially
asymptomatic and considered unimportant until loss
of appetite and vomiting ensued. In retrospect it is
noteworthy that in the early phases of this illness,
the patient took insulin and then ate a half hour
later. It can be conjectured that feedings were
retained in the esophagus until relaxation of the
cardioesophageal spasm permitted the food to pass
into the stomach, this delayed “feeding” causing
hyperglycemia and glycosuria, which was treated
with an increase in insulin. It can be conjectured
further that finally the dosage reached levels that
caused severe hypoglycemia, especially when food
was long delayed in the esophagus. Orange juice
and sugar relieved the hypoglycemia if the spasm
relaxed enough for it (but not the solid food) to
reach the stomach; otherwise intravenous glucose
was required. Then, when the patient became hypo-

VOL. 97, NO. 6 • DECEMBER 1962

363

glycemic, insulin dosage was reduced. Later when
the cardiospasm relaxed, allowing a large amount
of food not sufficiently counteracted by insulin to
enter the stomach, ketosis and sometimes coma
occurred. After the esophageal obstruction was re-
lieved by surgical operation, food reached the small
intestine normally and the “brittleness” of the pa-
tient’s diabetes disappeared.

SUMMARY

A patient with “brittle” diabetes in whom the
brittle feature was caused by initially asymptomatic
cardiospasm that prevented passage of food into the
stomach, is reported. Relief of the “brittle” aspect
occurred after esophagomyotomy was carried out.

1441 Westwood Boulevard, Los Angeles 24 (Rossman).

Cat Scratch Disease: Differential Diagnosis
Of Regional Adenopathic Changes

MELFORD B. JORGENSEN, M.D., Los Gatos

A 21-year-old boy was first seen 25 February,
1961, with complaint of swelling of three days’ dura-
tion in front of the right shoulder and in the right
axilla.

A sister of the patient had died at age three of
malignant neuroblastoma; an aunt had Hodgkin’s
disease. The patient had had only the usual child-
hood diseases. Results of tuberculin tests in school
always had been negative. He had had adenotonsil-
lectomy in 1957.

On 22 February, three days before he was first
examined, the patient had fallen and struck his right
scapular spine area on a piece of wood. Some two
weeks earlier he had been scratched over the right
scapular spine area by a stray cat had he had picked
up. The scratch was inflamed at first but then healed
rather rapidly.

Upon examination a large swollen area was noted
at the border of the right axilla and extending up-
ward anterior to the right shoulder area. There was
no other swelling and no nodal enlargement was
palpated. The first impression of the swelling was
attributable to traumatic hematoma. However, it did
not diminish over the next several days and the
patient began to have fever with temperature up to
101° F. in the evenings. On examination of the
ears, nose, throat and lungs no abnormality was
noted. The liver and spleen were not enlarged.

X-ray studies of the right shoulder area and of
the chest on February 28 were within normal limits.
Hemoglobin was 13 gm. per 100 cc. of blood.
Erythrocytes numbered 5,040,000 per cu. mm. and
leukocytes 10,300 — 42 per cent segmental forms,

Submitted April 30, 1962.

30 per cent lymphocytes, 10 per cent stabs, 1 per
cent juvenile forms, 2 per cent eosinophils and 15
per cent monocytes. On March 3, 1961, the hetero-
phil antigen was positive only in dilutions of 1:28.
A smear of the red blood cells and the platelets
appeared normal, as did the lymphocytes and mono-
cytes. Leukocytes numbered 10,700 per cu. mm.,
with 58 per cent segmental forms, 1 per cent bas-
ophils, 26 per cent lymphocytes, 5 per cent mono-
cytes and 10 per cent eosinophils. Reaction to an
intermediate strength tuberculin test was negative.

There were a few small, palpable lymph nodes
in the left axilla. A swollen area extending anteriorly
and superiorly from the right axilla appeared to be
made up of smooth nodules which were tender.
There was softness in the center of the area.

Because of the history of trauma and of the some-
what unusual location of the swelling extending
anteriorly and superiorly, hematoma had to be con-
sidered, and in light of the familial history of
malignant conditions, the possibility of disease of
that kind had to be taken into account. No cat
scratch disease antigen was available for a skin test.

As conservative treatment did not bring about
improvement, surgical biopsy was carried out 9
March 1961. The mass was found to be made up of
a conglomeration of lymph nodes varying in size
from lxl cm. to 2 x 2 cm. Evidence of acute
inflammatory process being noted, material from
the mass was cultured. (Later it was reported as
growing coagulase negative staphylococcus albus.)
The main portion of the mass presenting into the
incision wound was removed. A small drain was
inserted and the wound was closed loosely over it.

Pathologist’s report: The specimen consisted of
several masses of lymph nodes enmeshed in fat.
The nodes were succulent and up to 2 cm. in size.
The cut surface of one of them showed a pattern
suggesting small areas of focal necrosis with loss of
small, greyish-white ribbons of tissue from the cut
surface. On frozen section examination an inflam-
matory process suggestive of cat scratch disease was
noted. Microscopic examination of multiple sections
of the lymph nodes showed an acute inflammatory
process. Centrally the granulomas were undergoing
necrosis and surrounding this were epithelioid cells
in which a scattering of multinucleated foreign body
giant cells were seen. The centers of the small abscess
were richly infiltrated with polymorphonuclear leu-
kocytes. The inflammatory process extended into the
surrounding connective tissue and fat. There was no
evidence of malignant change.

The pathologic diagnosis was lymphadenitis, acute,
with multiple abscess formation, right axillary
lymph nodes. Inflammatory process consistent with
cat scratch disease. The tissue specimens were re-
viewed by Stewart Lindsay, M.D., of the Pathology
Department of the University of California Hospital,
San Francisco, who concurred in the diagnosis of
cat scratch disease.

364

CALIFORNIA MEDICINE

DISCUSSION

The diagnosis of the cat scratch disease is made
by remembering to consider it among the various
differential diagnoses usually considered in cases
of regional adenopathy, by the presence of tender
centrally necrotic lymph nodes, a history of contact
with a cat, especially of being scratched by one,
and by the use of the cat scratch antigen skin test.
A large important area of differential diagnosis
includes that of mesenteric adenitis and appendicitis,

although the commonest areas of lymphadenopathy
are the axillary and cervical areas.

SUMMARY

In the case of cat scratch disease here reported,
diagnosis was complicated by a history of blunt
trauma to the area of axillary swelling, a family
history of malignant disease and lack of cat scratch
disease antigen for skin testing.

Corner of Massol and Saratoga Avenues, Los Gatos.

VOL. 97, NO. 6 •

DECEMBER 1962

365

^ ^MEDICINE

For information on preparation of manuscript, see advertising page 2

DWIGHT L. WILBUR, M.D Editor

ROBERT F. EDWARDS . . . Assistant to the Editor

Policy Committee — Editorial Board

OMER W. WHEELER, M.D. Riverside

SAMUEL R. SHERMAN, M.D San Francisco

CARL E. ANDERSON, M.D Santa Rosa

JAMES C. DOYLE, M.D Beverly Hills

MATTHEW N. HOSMER, M.D San Francisco

IVAN C. HERON, M.D San Francisco

DWIGHT L. WILBUR, M.D San Francisco

EDITORIAL

The Keogh Bill

In the past ten years physicians throughout the
country have paid tribute to one Keogh, a member
of the House of Representatives. He is the man
whose name has consistently been linked with a
legislative bill to permit self-employed persons to
take a tax deduction for funds they put aside into
a retirement program.

This hill has now been approved by both houses
of the Congress and signed into law by the Presi-
dent. It goes into effect January 1, 1963, which
means that these self-employed persons will be able
to take the tax deduction in April, 1964, on their
calendar year 1963 income tax returns.

In the glad tidings flowing from the passage of
this measure, it would appear that the name Keogh,
while still remembered, means little more than Smith
or Jones to the great number of physicians who will
get both a measure of tax relief and a measure of
retirement stability from this new law.

To set the record straight, Mr. Keogh is a resi-
dent of Brooklyn, N. Y. His full name is Eugene
J. Keogh, he is a law graduate of New York Univer-
sity and Fordham University Law School, and he
was serving as a member of the New York State
Assembly when, in 1936, he was first elected to the
Congress. He has been reelected regularly since that
time. He is a Democrat.

Mr. Keogh first put his bill into the Congress ten
years ago. It got nowhere at the outset but within
a few years had attracted support from other Con-
gressmen. About six years ago it was adopted by
the House of Representatives but died in the Senate.
This history was repeated in each session of Con-
gress until 1962, when the Senate also passed the
bill. There was speculation that the President might
veto the measure, even in the watered-down form of
its adoption, but facing the prospect that a veto
would be overridden, he signed it.

In its present form the Keogh Law will permit
self-employed persons to establish retirement pro-

grams and to deduct half of the program cost, up
to a maximum of $1,250 in deductions, from their
income tax returns each year. The deduction is from
gross income, not from taxes payable.

The law also requires that a self-employed person
setting up his own retirement plan and claiming
the tax deduction must also set up a retirement plan
for his employees who have been in his employ for
three years or more.

On retirement, the self-employed person will be
subject to income taxes on his cash receipts from
his program. Thus tax deductibility for cost figures
now will result in tax charges when funds are drawn
from the program. This is a tax break for the indi-
vidual in that today’s deductions will take gross
income from the top tax bracket, while income after
age 65 will call for taxes on a presumably deci'eased
annual gross income.

These are the basics of the law. Like most federal
legislation, the Keogh Law is a skeleton on which
regulatory rules and regulations must be draped by
Internal Revenue Service. The usual procedure is for
IRS to draft rules and regulations and to submit
them to public hearings. Facts developed in such
hearings will then be incorporated in revised rules,
which will again be put up for public scrutiny.

These procedures will take several months at least.
Thus those directly benefited by the law will not
know until some time in 1963 the procedures that
will qualify or disqualify a specific retirement pro-
gram. Since no income received before January 1,
1963, will be affected, the taxpayer will have until
April 15, 1964, to claim his own tax deduction for
his own plan.

Meanwhile, the woods are rapidly filling with tax
consultants, investment advisors, insurance agents
and a host of “experts” willing to sell their own
plans or programs to the self-employed persons who
are finally getting a tax break.

The Council of the California Medical Associa-
tion has noted this influx of advisors-with-portfolio

366

CALIFORNIA MEDICINE

and has agreed on a simple statement at this time:
take your time and don’t rush into a program until
all the facts are known.

An individual who starts a program now, in the
absence of official ground rules, is running the risk
that his plan may not meet the qualifications of the
regulations yet to be issued. It would be most un-
fortunate for a physician to contribute to a plan
developed hurriedly and find out, a year later, that
the plan is not qualified and that his contribution
to it is not tax deductible.

Because of the extreme interest which physicians
have demonstrated in the Keogh program, medical
society offices have been in the forefront for visits
by the “experts’’ who have their own plans to sell.
For this reason the Medical Executives Conference,
comprising the top staff members of the C.M.A. and
the component societies, has entered into a study of
the new law with full knowledge of the implications
inherent in this type of legislation.

At the last Council meeting the conference made
a report which could be summarized in two words:
go slow.

The Medical Executives Conference has estab-
lished a special committee of its members to delve
into all aspects of retirement plans for the self-
employed. This committee will follow the progress
of rules and regulations as they are developed and
finally adopted and will be in position to offer
suggestions for the guidance of all physicians.

The C.M.A. Council has warmly applauded this
move, has voted in favor of the concept of such a
committee and has agreed to consider requests for
such modest financing as the committee may need
for tax, accounting and investment consultants.

The Council has recognized the present situation
as one which will attract any number of salesmen,
each with his own concept of an acceptable program
and each with his silver tongue adjusted to the
desire of each self-employed physician to provide
for his own future and to gain a small measure of
tax relief in the process.

The unanimous decision of the Council and of
the staff executives of the state and component
societies is: Go slow!

^ r MEDICAL

ASSOCIATION

NOTICES & REPORTS

Council Meeting Minutes

Tentative Draft: Minutes of the 485th Meeting of
the Council Los Angeles, Biltmore Hotel, Novem-
ber 3, 1962.

The meeting was called to order by Chairman
Anderson in Conference Room No. 1 of the Bilt-
more Hotel, Los Angeles, on Saturday, November
3, 1962, at 10:00 a.m.

Roll Call:

Present were President Wheeler, President-Elect
Sherman, Speaker Doyle, Vice-Speaker Heron, Sec-
retary Hosmer, Editor Wilbur and Councilors Mac-
Laggan, Wilson, Todd, Quinn, Bullock, O’Connor,
Ham, Rogers, Dalton, Murray, Davis, Miller, Watts,
Campbell, Morrison, Kaiser, Anderson, Dozier, Cos-
entino and Grunigen. Absent for cause, Councilor
O’Neill.

A quorum present and acting.

Present by invitation were Messrs. Hunton,
Thomas, Clancy, Collins, Clark, Marvin, Whelan,
Klutch and Bowman, Doctors Batchelder and Miller
and Mrs. Griffith of staff ; Messrs. Hassard and
Huber of legal counsel; Messrs. Read and Salis-
bury of the Public Health League; county execu-
tives Lingerfelt of Fresno, Geisert of Kern, Field,
Dalbec and Williams of Los Angeles; Brayer of
Riverside, Burris of San Diego; Donmyer of San
Bernardino, Blankfort of Marin and Brown of So-
noma; Doctor Malcolm Merrill, State Director of
Public Health; Doctor Daniel Blain, State Director
of Mental Hygiene; Doctor Lester McDonald of the
State Department of Social Welfare; Doctors Rob-
ert Purvis of Stanislaus County, T. Eric Reynolds
of California Physicians’ Service; Robert Shell of
Marin County, Harold Kay, John M. Rumsey and
Warren L. Bostick; Mr. John Pompelli of the Amer-
ican Medical Association; and California Delegates
to the A.M.A., Doctors J. B. Price, Ralph Teall,
Donald A. Charnock, J. Lafe Ludwig, Eugene F.
Hoffman, James E. Feldmayer, Charles B. Hudson,

Henry Gibbons, III, Leopold H. Fraser and Arlo A.
Morrison, and others.

1. Minutes for Approval:

On motion duly made and seconded, minutes of
the 484th meeting of the Council, held September
29, 1962, were approved.

2. Membership:

(a) A report of membership as of October 31,
1962, was presented and ordered filed.

(b) On motion duly made and seconded, 26
delinquent members whose dues have been paid were
voted reinstatement.

(c) On motion duly made and seconded in each
instance, six applicants were voted Associate Mem-
bership. These were: Paul Hayes, Betty Kiger, Ala-
meda-Contra Costa; James M. Casey, Fresno County;
James W. Fullerton, David Boska, Los Angeles
County; Robert H. Berger, Orange County.

(d) On motion duly made and seconded in each
instance, five members were voted Retired Mem-
bership. These were: Ernest Aronstein, Fresno
County; George I. Sellon, Orange County; Emmett
L. Tisinger, San Bernardino County; Charles G.
Jobbins, Hilmar O. Koefod, Santa Barbara County.

OMER W. WHEELER, M.D President

SAMUEL R. SHERMAN, M.D President-Elect

JAMES C. DOYLE, M.D Speaker

IVAN C. HERON, M.D Vice-Speaker

CARL E. ANDERSON, M.D. . . Chairman of the Council
BURT L. DAVIS, M.D. . . . Vice-Chairman of the Council

MATTHEW N. HOSMER, M.D Secretary

DWIGHT L. WILBUR, M.D Editor

HOWARD HASSARD Executive Director

JOHN HUNTON Executive Secretary

General Office, 693 Sutter Street, San Francisco 2 • PRospect 6-9400
ED CLANCY Director of Public Relations

Southern California Office:

1515 N. Vermont Avenue, Los Angeles 27 • 663-8071

368

CALIFORNIA MEDICINE

(e) On motion duly made and seconded in each
instance, reductions of dues were voted for five
members because of illness or postgraduate study.

3. Public Health:

Doctor Malcolm Merrill, State Director of Public
Health, reviewed several federal legislative acts
which will affect the public health program in Cali-
fornia. He also reported that influenza vaccine has
had about double last year’s use during 1962 and
that supplies of the vaccine are almost at the van-
ishing point and new supplies not anticipated for
some months.

Doctor Merrill also reported that Doctor Charles
E. Smith, dean of the School of Public Health of
University of California, has been awarded the
Bronfman Award by the American Public Health
Association. This award carries a handsome trophy
and a cash award of $5,000. On motion duly made
and seconded, it was voted to commend Doctor
Smith on this achievement.

4. Mental Hygiene:

Doctor Daniel Blain, State Director of Mental
Hygiene, supplied the Council with two pamphlets
outlining the department’s use of both public and
private facilities and its in-training program for
psychiatrists and its long-range program aimed at
utilizing an increasing number of private facilities
and physicians.

Doctor Blain also reported on the number of hos-
pital beds now in use and the relative decrease in
number of patients under treatment in state mental
hospitals. He stated that his department will seek
assistance from the Association in its legislative
program and suggested that the Committee on
Mental Health be strengthened and possibly en-
larged.

Doctor Wheeler supplemented this report by
reporting on the recent Mental Health congress
staged by the American Medical Association, at
which there were 1,700 registrants, including 75
from California. This report was ordered referred
to the Committee on Mental Health, with instruc-
tions to study and report back at the next Council
meeting.

5. Social Welfare:

Doctor Lester McDonald, medical director of the
State Department of Social Welfare, gave a statisti-
cal report on welfare medical care programs. As of
the end of September, 1962, he reported 6,300
patients hospitalized under the Medical Assistance
to the Aged program and another 9,300 patients in
nursing homes. In September, he reported, 1,660 ap-
plications for aid, of which 61 per cent were receiv-
ing some form of aid at time of application.

Doctor McDonald also reported a noticeable im-
provement in the attitude of social welfare workers
toward the medical profession.

6. California Physicians’ Service:

Doctor John G. Morrison, C.P.S. board chairman,
reported that more than 13,500 inquiries had been
received in the first two days following announce-
ment of the new Senior Citizens programs and
about 600 applications have now been processed.
He stated that a report would be given the Council
later on actions taken on 1962 House of Delegates
resolutions.

7. Medical Executives Conference :

Mr. Hassard and Mr. Dalbec, reporting for the
Medical Executives Conference, stated that in re-
sponse to Resolution No. 20 of the 1962 House of
Delegates, a canvass of medical society executives
showed that the component societies are maintaining
a close liaison with various county departments
which deal with the provision of medical care.

Mr. Hassard also reported that the members of
the conference had given much thought to programs
which may be developed under the terms of the
Keogh Bill, to permit tax deductions for the estab-
lishment of retirement programs for the self-em-
ployed. The conference has established a committee
to follow this matter and the committee has ex-
pressed the need for great caution on the part of
individual physicians before initiating programs of
their own. Regulations to govern acceptable plans
have not yet appeared and are not anticipated for
several months. Meanwhile, tax and investment ad-
visors are making offerings. Mr. Hassard asked
that the Council (1) approve the concept of a fact-
finding committee of the conference for the purpose
of gathering and analyzing various programs which
may be offered, and (2) approve moderate expen-
ditures which may be needed to secure expert con-
sultation from tax and investment counsel. On
motion duly made and seconded, it was voted to
approve the concept of this committee and to refer
to the Finance Committee the matter of funds in
moderate amounts for its work.

8. Report of the President:

Doctor Wheeler outlined the program of the con-
ference of component society officers to be held
January 12-13, 1963 in Los Angeles. Invitations will
be extended to each component society president and
four additional society representatives of his choos-
ing. Transportation expenses will be met by the
Association.

Doctor Wheeler also stated that a report on rec-
ommendations in the Bryan communications report

VOL. 97. NO. 6 • DECEMBER 1962

369

would be prepared by the ad hoc committee to re-
view these recommendations and copies will be sent
to all members of the Council.

9. Report of President-Elect:

Doctor Sherman reported on several meetings he
had attended, including an A.M.A. conference on
society programs and a joint conference on quackery
sponsored by the A.M.A. and C.M.A.

Doctor Sherman also reported that consideration
was being given to proposed legislation which would
provide rehabilitation services to victims of indus-
trial accidents. He suggested that the Liaison Com-
mittee on Social Welfare and the Committee on
Legislation should follow these proposals. On mo-
tion duly made and seconded, it was voted to
authorize the above committees to participate in
conferences on these proposals and to report back
to a later Council meeting.

10. Committee on Committees:

Doctor Sherman proposed that a liaison commit-
tee to the State Board of Medical Examiners should
be established, to work with the board on legislative
and other matters of mutual interest. On motion
duly made and seconded, the creation of such a
committee was approved.

11. Delegates to A.M.A.:

Doctor Wilbur, chairman of the A.M.A. delega-
tion, presented a statement of principles on health
insurance prepared by an ad hoc committee under
his chairmanship. The statement was approved in
principle but no formal action taken.

Doctor Wilbur also presented three proposed
resolutions which may be presented to the A.M.A.
House of Delegates, covering the provision of medi-
cal services to the aged. On motion duly made and
seconded, all three were approved in principle,
subject to changes in language but not concept. A
copy of the statement of principles and the three
resolutions is appended to and made a part of these
minutes.

12. Finance Committee :

Doctor Davis reported that the Finance Com-
mittee has held its initial meeting on the 1963-1964
budget and will meet again to place the budget in
proper form for presentation to the Council.

Doctor Davis also reported that the Finance Com-
mittee had approved an appropriation of an addi-
tion $18,000 to finance the campaign for passage
of Proposition 22 on the November 6 ballot. On
motion duly made and seconded, this appropriation
was voted unanimously.

13. Bureau of Research and Planning:

Doctor Gerald W. Shaw, chairman of the Bureau
of Research and Planning, reported that a compila-
tion of voluntary plans to provide prepayment med-
ical care services to the over-65 group has been
completed. On motion duly made and seconded, it
was voted to approve distribution of this compila-
tion to the component societies and to refer to the
Bureau on Communications a study of possible
additional distribution.

14. Liaison Committee to Hospital Association:

Doctor MacLaggan, chairman of the Liaison
Committee to the California Hospital Association,
reported on several symposia on hospital adminis-
tration, staff principles and similar topics recently
attended by himself and by Doctor Batchelder.
Among those attending were a number of staff
physicians and hospital trustees.

15. Ad Hoc Committee on Polio Immunization:

Doctor MacLaggan stated that a meeting of the
ad hoc committee on polio immunization had
given consideration to the Type III Sabin vac-
cine. Despite its withdrawal from usage at this
time, Doctor MacLaggan stated that a large portion
of the overall immunization program will be com-
pleted with the administration of the other two types
of vaccine and that the committee was hopeful of a
modification of opinion by the Surgeon General to
permit the administration of Type III. At his
request he was granted authority to develop a state-
ment along these lines, along with the State Depart-
ment of Public Health.

16. Committee on Government Financed Medical
Care:

Doctors John Murray and John Rumsey reported
that the present Medicare contract, covering de-
pendents of service personnel, would expire next
February. They asked (1) clarification of the com-
mittee’s relationship with California Physicians’
Service, which administers the program in Califor-
nia, (2) authority to negotiate with the Department
of Defense, and (3) authority to speak in behalf
of the medical profession in California. On motion
duly made and seconded, it was voted to authorize
the Committee on Government Financed Medical
Care to discuss with the Department of Defense the
renegotiation of the Medicare contract and to pre-
sent evidence on the current level of medical fees
in California.

17. Commission on Medical Services:

Doctor Murray gave a progress report on a study
of the costs of carrying on a medical practice. He

370

CALIFORNIA MEDICINE

also reported that consideration had been given to
resolutions 16, 37 and 41 of the 1962 House of
Delegates and that the commission’s report on them
will be given the Council at a later date.

18. Commission on Community Health Services:

fa) Doctor Harold Kay, chairman of the Com-
mission on Community Health Services, gave prog-
ress reports on the activities of several committees.
For the Committee on School Health he presented
a form developed for a physician’s report on exam-
ination of school children. On motion duly made
and seconded, this form was approved.

A statement by industrial nurses on the use of
closed chest resuscitation was presented and, on
motion duly made and seconded, voted approval.

The “Health Tips” column is now being used by
nine school districts and 37 additional newspapers
have been added to the mailing list.

(b ) For the Committee on Traffic Safety he sug-
gested that the committee serve in a consultative
capacity with the Department of Motor Vehicles as
regards physical requirements for driver licenses.

Doctor Kay also suggested that the Department
of Motor Vehicles be asked to over-print in large
letters the “M.D.” insignia on licenses issued to
physicians and this imprinting be accepted as clear-
ance for physicians through police lines or other
barriers in case of emergencies. On motion duly
made and seconded, approval was voted for this
procedure.

(c) Doctor Robert Purvis, chairman of the Com-
mittee on Blood Banks, presented a statement
adopted by the committee, to insure proper and
adequate personnel and facilities in all depots where
California member blood banks would deliver blood
supplies. On motion duly made and seconded, this
statement was approved.

Doctor Purvis also reported that the California
Blood Bank System was being reorganized along
lines to permit it to work closely with the national
and regional organization of the American Associa-
tion of Blood Banks. He asked that the Association
support this form of reorganization and co-sponsor
it in California. On motion duly made and seconded,
it was voted to establish a blood bank committee of
not more than three members and that the reorgani-
zation of the system be co-sponsored by the Asso-
ciation.

fd) Councilor Wilson reported on a recent acci-
dent in Orange County, where a heavy gravel truck
had collided with a moving railroad train, with two
deaths and numerous injuries resulting. Physicians
called to the scene were confronted with a traffic
jam but walked a considerable distance to provide
their services. This demonstration of emergency

service, he reported, drew high praise from the
community.

19. Bureau on Communications :

Doctor Warren L. Bostick, chairman of the Bu-
reau on Communications, presented a set of criteria
to be used by component societies which seek Asso-
ciation financial support of locally developed public
relations programs. The criteria would call for the
program to have statewide implication and applica-
tion, for its approval by the bureau and its sub-
mission to the Council and its Finance Committee.
On motion duly made and seconded, these criteria
were approved.

Doctor Bostick also presented a request for the
appropriation of an additional $27,500 for the
production of an additional 11 television programs
in the “Doctors At Work” program. He also sug-
gested that a study of audience reaction to the
program be carried out with funds already avail-
able. On motion duly made and seconded, it was
voted to refer this request to the Finance Committee
for study and recommendation at the next Council
meeting.

20. Legal Department:

Mr. Hassard gave further report on the confusion
created by passage of H.R. 10, the Keogh Bill, to
provide tax deductions for limited funds put into
retirement programs by the self-employed.

Mr. Hassard also reported on a recent State
Supreme Court decision requiring a public district
hospital to admit to its staff a physician who had
been denied staff admission on grounds of incom-
patibility with staff and other hospital personnel.

21. Judicial Commission:

Councilor Davis reported on a request made by
a component society for creation of a district judi-
cial council under the terms of Chapter III of the
Bylaws. He presented a list of members in the dis-
trict for appointment to this council and asked
approval of the list. On motion duly made and
seconded it was voted to approve the appointment
of such district judicial council, recognizing that
both Doctor Davis and Doctor Albert Miller, Coun-
cilors from the district, were in agreement on the
nominees.

22. Commission on Cancer:

Doctor Davis, chairman of the Commission on
Cancer, reported that a study on the needs of cancer
patients had been completed and referred to the
Califonia Division of the American Cancer Society
for study and implementation. He also asked that a
condensation of this study be considered for pub-

VOL. 97. NO. 6 • DECEMBER 1962

371

lication in California Medicine. On motion duly
made and seconded, it was voted to refer this study
to the journal for consideration for publication.

Doctor Davis also requested a vote of commen-
dation for Doctor James C. Doyle for his having
moderated the recent A.M.A.-C.M.A. Conference on
Quackery, much of which had to do with cancer.
By voice vote the Council concurred.

23. Attendance at Council Meetings:

Doctor MacLaggan suggested that the president
of the California Hospital Association be invited to
attend Council meetings. On motion duly made and
seconded, it was voted to extend this invitation.

Adjournment:

There being no further business to come before
it, the meeting was adjourned at 6:00 p.m.

Carl E. Anderson, M.D., Chairman
Matthew N. Hosmer, M.D., Secretary

Principles of a Sound Program for
Medical Care

An ad hoc committee was appointed by the Coun-
cil to develop principles which the medical profes-
sion can adopt as a sound and supportive basis for
the provision of medical services to those persons
who are not able to meet the cost of such services
from their usual resources.

This committee met on September 28 and agreed
on the principles listed below as a starting point for
development of a program which would (1) assure
the delivery of needed medical services to the peo-
ple, (2) assure the maintenance of sound scientific
tenets, and (3) outline methods by which such
services could be financed.

1. Financial responsibility for the care of the
patient is initially his own. Should financial re-
sources be unavailable to the patient or his family,
responsibility then flows to the local community
and from there to the county, to the state and, only
as a last resort, to federal government. Government
at all levels has a financial responsibility and a role
to play in the provision of funds for the care of
those who are in need of medical services and who
lack the resources to purchase adequate health care
protection.

2. The voluntary insurance programs through
prepayment offer the most effective and versatile
approach to financing health care. They already
have, in the past several decades, demonstrated un-
precedented growth and expansion and they possess
the potential of further expansion if given the op-

portunity of refinement, enrichment and experimen-
tation.

3. These principles have already demonstrated
their versatility and effectiveness in the care of
millions of Americans, including the medically
needy. For example, the Kerr-Mills approach is in
keeping with this method of financial responsibility
in the medically needy group.

In some areas, however, especially where state
enabling legislation is not yet sufficiently broad, it
appears that local and state programs need to be
extended to additional beneficiaries. Existing needs
for broadening such coverage do not negate the
philosophy of financial responsibility recognized in
these programs.

4. Additional groups including the financially or
medically needy may be assisted in financing the
costs of medical care services through tax deduc-
tions, tax credits or other incentives. These could
be allowed to the patient or to members of his
family who assume the financial responsibility for
his medical care even though they may not claim
the patient as an exemption under federal or state
income tax laws.

5. Another approach for the medically needy
would be through cash allowances for premiums for
voluntary prepaid health insurance through a sliding
scale of cash allowances adequate to permit the
purchase of sound health care protection.

RESOLUTION NO. 1

Whereas, the 87th Congress declined adoption of
King- Anderson legislation; and

Whereas, programs for assisting the needy aged
or the medically indigent aged need further study,
refinement and extension; and

Whereas, the Kerr-Mills program is the law of
the land and has been approved by the medical
profession and has been successful in some areas but
has not had an opportunity to demonstrate its
effectiveness in other areas; and

Whereas, enabling legislation has been adopted
in some states while not in others and in some of
those areas where enabling legislation has been
enacted it may require modification or broadening
on the basis of experience to be more effective and
efficient; and

Whereas, Kerr-Mills implementation has lagged
or been inadequate in some areas because political
figures have, for reasons of their own, seen fit to
deter such implementation or physicians, also for
reasons of their own, have not encouraged or
stimulated state and local participation; and

Whereas, Kerr-Mills legislation is in accord with
principles approved by the American Medical Asso-

372

CALIFORNIA MEDICINE

ciation and is legislation already on the federal
statute books which is capable of stimulating and
supplementing local and state health care programs
for the needy or near-needy; now, therefore, be it
Resolved: That the American Medical Association
use its good offices and influence in urging all com-
ponent associations to strengthen, expand or other-
wise modify Kerr-Mills enabling legislation in those
states where such legislation is needed and has been
enacted, to the end that effective and valuable
methods of health care may be provided to aged
recipients, where the need exists, under terms ap-
proved by physicians; and be it further

Resolved: That improvements in existing Kerr-
Mills enabling legislation should be sought; for
example, in (a) lowering waiting periods for eli-
gibility, (b) establishment of a dollar deductible
for applicants rather than a time period, (c) removal
of administrative regulations which debar some
applicants from eligibility if they have been receiv-
ing aid from welfare funds, and other means, all
of which should be explored by the various states;
and be it further

Resolved: That the American Medical Association
urge those component associations in areas where
Kerr-Mills enabling legislation has not yet been
enacted but where local and state programs need
further stimulus or financial help from Federal
“grants-in-aid” to use their utmost efforts in secur-
ing the adoption of adequate enabling legislation for
this purpose.

RESOLUTION NO. 2

Whereas, the financing of medical and health
services has in recent history become a political
consideration; and

Whereas, voluntary prepayment and insurance
plans have been developed in the past thirty years
as a means of permitting people to budget for these
costs and these plans have been spectacularly ap-
proved and accepted by the American people; and
Whereas, universal inflationary forces have re-
quired that the cost of providing health care serv-
ices be increased, and such increases in the cost of
prepayment and insurance coverage have had the
double effect of (1) decreasing the coverage avail-
able where the cost paid does not keep pace with
the cost of services to be provided, and (2) creating
fuel for political claims that costs are at a level
requiring governmental seizure of the entire field
of furnishing and financing health care; and

Whereas, political figures recognize the cost fac-
tor in providing prepayment as a political factor
but to date have given little or no recognition to
the costs involved to individual taxpayers; now,
therefore, be it

Resolved: That the American Medical Association
through its Board of Trustees, its Councils, its staff
and consultants use every possible effort to secure
federal enactment of legislation which will permit
tax deductions, tax credits or other monetary in-
centives to those who assume the cost, including
those of adequate voluntary prepaid plans, of pro-
viding health care services for the needy or near-
needy aged group of citizens.

RESOLUTION NO. 3

Resolved: That the American Medical Association
endorse the principle in the care of the medically
needy which will permit allowances for premiums
for voluntary prepaid health insurance adequate to
purchase sound health care. The amount of such
allowances should be based on a sliding scale of in-
come and in keeping with the principle that the
government at all levels, national, state and local,
has some financial responsibility in the care of the
medically needy. Determination of need and admin-
istration should be at the local level.

PROPOSED AMENDMENTS
TO CONSTITUTION

Amendments to the Constitution of the California
Medical Association are required to lie on the table
for one year before being voted upon. Six proposed
amendments to the Constitution were introduced in
the 1962 House of Delegates. Under the terms of
the Constitution, these were subject to review by the
Reference Committee in the 1962 House of Dele-
gates and will also be reviewed by Reference
Committee No. 4 in the 1963 House before being
voted upon in that session. In five instances the
1962 Reference Committee made specific recom-
mendations which were adopted by the House and
are shown following the proposals.

In some instances the Reference Committee sug-
gested that proposed amendments to the By-Laws,
which need lie on the table only twenty-four hours,
also be deferred until 1963 because of their associ-
ation with constitutional amendments on the same
subject. In the section on By-Law Amendments
following this section, such deferral will be noted.

The following Amendments to the Constitution
were offered in 1962, all of them placed on the table
for definitive action in 1963.

iii

1962 AMENDMENTS

Six proposed amendments to the Constitution
were introduced in the 1962 House of Delegates.
They were reviewed by Reference Committee No. 4

VOL. 97, NO. 6 • DECEMBER 1962

373

of the 1962 House of Delegates and will also be
reviewed by Reference Committee No. 4 of the 1963
House. In certain instances the 1962 Reference Com-
mittee made certain specific recommendations which
were adopted by the House.

CONSTITUTIONAL AMENDMENT No. 1

Author: Samuel R. Sherman.

Representing: The Council.

Resolved : That Article I, Section 3 of the Con-
stitution of the California Medical Association as
now written be deleted and this section to read as
follows :

/ i i

CONSTITUTIONAL AMENDMENT No. 2

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Article III, Section 1, be
amended by deleting the word “and” at the end
of subsection (c), and by adding a new subsection
(d) to read as follows:

“(d) Ex-officio with the right to vote, eighteen
(18) members of the Scientific Board selected as
provided in the Bylaws, and”

The present subsection (d) shall be redesig-
nated (e).

v ' i 1 1

CONSTITUTIONAL AMENDMENT No. 3

Author: Samuel R. Sherman.

Representing: The Council.

Resolved: That Article III, Part B, Section 9,
of the Constitution of the California Medical Asso-
ciation shall be amended by inserting a new
subparagraph (c) and redesignating the present
subparagraph (c) as (d), and the present subpara-
graph (d) as (e). The new subparagraph (c) shall
be inserted immediately after subparagraph (b)
and shall read as follows:

CONSTITUTIONAL AMENDMENT No. 4

(Printed with Action following Constitutional
Amendment No. 5)

CONSTITUTIONAL AMENDMENT No. 5

Author: Dwight L. Wilbur.

Resolved: That Article III, Part A, Section 1,
be amended by deleting the word “and” at the end

of subsection (c), and by adding a new subsection
(d) to read as follows:

“(d) Ex-officio, with the right to vote, the mem-
bers of the Scientific Board, and”

The present subsection (d) should be redesig-
nated as (e) .

1 1 i

CONSTITUTIONAL AMENDMENT No. 4

Author: Los Angeles delegation.

Whereas, the Council of the C.M.A. is an im-
portant group in carrying on the activities of the
C.M.A. ; and

Whereas, it is important that the members of
the Council be responsive to the desires of the ma-
jority of the members of the C.M.A.; and

Whereas, a democratic organization provides a
vote to all its members; now, therefore, be it

Resolved: That the Constitution of the C.M.A.,
Article III, Part B, Section 11, be amended to read
as follows:

“Section 11 — Election of Councilors

“District Councilors shall be elected by the vote
of the members, entitled to vote, from each District,
in the manner and at the time specified in the By-
laws.”

and be it further

Resolved: That the Bylaws of the C.M.A. be
amended to provide for the election of District
Councilors in accordance with this Constitutional
amendment.

ACTION: Constitutional Amendment No. 4 (to-
gether with Bylaw Amendment No. 12 printed under
1962 Bylaiv Amendments) was referred to a special
ad hoc committee to be appointed by the Speaker
with instructions to study the proposals and make
a report to the House of Delegates at its next annual
session.

CONSTITUTIONAL AMENDMENT No. 6

Author: Allyn J. McDowell.

Representing: Los Angeles.

Resolved: That the Constitution of the Califor-
nia Medical Association be amended by adding to
Article I, Section 2, the following:

“This Association shall not have the right to enter
into a contract with any person, firm, or agency of
any kind with respect to the practice of medicine or
fees for such practice.”

374

CALIFORNIA MEDICINE

BYLAW AMENDMENTS FOR ACTION IN 1963

Two proposed amendments to the By-Laws intro-
duced in the 1962 House of Delegates were, on
recommendation of the Reference Committee and
vote of the House, deferred for consideration until
1963. These are shown here as introduced in 1962
and as identified, numerically, in the 1962 meeting.

The Reference Committee also suggested that a
special committee be established, to review these
deferred amendments. This committee, which has
been established by the Speaker, will review all
amendments to the Constitution and the By-Laws
which relate to the structure of the Association.

Shown below are the amendments to the By-Laws
introduced in 1962 and deferred for action in 1963.

BYLAW AMENDMENT No. 12

Author: Los Angeles delegation.

Whereas, the Council of the C.M.A. is an im-
portant group in carrying on the activities of the
C.M.A. ; and

Whereas, it is important that the members of the
Council be responsible to the desires of the majority
of the members of the C.M.A. ; and

Whereas, a democratic organization provides a
vote to all its members; now, therefore, be it

Resolved: That the Bylaws of the C.M.A., Chap-
ter VIII. Section 6 and Section 6.5 be amended to
read as follows:

“Section 6 — Election of District Councilors in Districts
Having One or More Councilors

previously established for offices in the same nu-
merical sequence, heretofore established, and there-
after for a term of three (3) years.”
and be it further

Resolved: That Section 6.5 of Chapter VIII of
the Bylaws of the C.M.A. be repealed and stricken
from the Bylaws.

ACTION: Bylaw Amendment No. 12 (together t vith
Constitutional Amendment No. 4 printed under 1962
Constitutional Amendments) teas referred to a special
ad hoc committee to be appointed by the Speaker
with instructions to study the proposals and make a
report to the House of Delegates at its next annual
session.

1 i 1

BYLAW AMENDMENT No. 13

Author: Allyn J. McDowell.

Representing: Los Angeles.

Whereas, the C.M.A. Bylaws have heretofore
provided for a referendum vote of all the members
only at the discretion of either the Council or the
House of Delegates; and

Whereas, these two referring bodies constitute
the very bodies concerning whose decisions any
appeal of the members might be needed or sought;
and

Resolved: That Chapter XII, Section 1 be
amended by adding the following:

“Any action taken by the Council or by the House
of Delegates may be referred to all of the active
members of the Association for their vote for or
against repeal of such action if a petition requesting
such a referendum is filed with the president of the
Association within sixty days after the action is
taken and if the petition is signed by a number of
active members amounting to more than twice the
number of voting delegates at the prior meeting of
the House of Delegates. This number of petitioners
shall constitute a referring body”; and be it further

Resolved: That Chapter XII, Section 2 be
amended by adding the following:

ACTION : Referred to a special ad hoc committee
to be appointed by the Speaker with instructions to
study the proposals and make a report to the House
of Delegates at its next Annual Session.

VOL. 97. NO. 6 • DECEMBER 1962

375

1963

Symposium on the
Adrenal Cortex

Annual Session

Symposium on the Pancreas

CALIFORNIA MEDICAL ASSOCIATION

Panel on Diabetes

March 23 to 27

Problems of Gonadal Function

AMBASSADOR HOTEL • LOS ANGELES

Spotlight on Medicine

Twenty-One Specialty Group
Meetings

GENERAL THEME:

Basic Science Session

Endocrinology and Inborn
Errors of Metabolism

Fourteen Medical Motion
Picture Symposia

5 OUTSTANDING GUEST SPEAKERS:

STEFAN S. FAJANS, M.D., Professor of Internal
Medicine, Division of Endocrinology and Metabo-
lism, University of Michigan Medical Center, Ann

Presidents’ Dinner Dance —
Sunday, March 24 —
Cocoanut Grove

Arbor.

MELVIN M. GRUMBACH, M.D., Associate Professor
of Pediatrics, College of Physicians and Surgeons
of Columbia University, New York.

House of Delegates —

Opening Session,

Saturday, 7:00 p.m., March 23;
T uesday Afternoon, March 26,
and Wednesday, March 27

GEORGE J. HAMWI, M.D., Professor of Medicine
(Endocrinology), Director, Division of Endocrinol-
ogy and Metabolism, Director of Clinical Research,

Ohio University College of Medicine, Columbus;
and President of the Ohio State Medical Asso-
ciation. :

Cancer Conferences on
Pathology and Radiology —
Saturday, March 23

Registration Daily —
No Registration Fee

CHARLES W. LLOYD, M.D., Senior Scientist; Direc-
tor of the Training Program of Reproductive
Physiology and Director of the Endocrine Research
Clinic, Worcester Foundation for Experimental

HOTEL RESERVATIONS— MAKE
ALL HOTEL RESERVATIONS THROUGH
C.M.A. HOUSING BUREAU—

Biology, Shrewsbury, Massachusetts.

SEE PAGE 378

No. 14*

Pre-Placement Physical Examinations—

Asset or Liability ?

There have BEEN indications in the literature recently of some doubt on the part of
those responsible for occupational health programs as to the usefulness of routine
pre-employment or pre-placement examinations.

We admit the validity of economic objections to such examinations, namely,
cost in time, personnel, and equipment; but wish to point out that the benefits far
outweigh the losses mentioned.

A California appellate court rendered an opinion recently involving aggravation
of a pre-existing disability where no baseline had been established by the employer.
The court advised : “It will be well to be diligent in ascertaining, at the very inception
of the employment relation, all available or discoverable facts relevant to the pro-
spective employee’s physical condition.”

Administrative codes prescribe medical supervision of agricultural workers ex-
posed to injurious materials. An important aspect of this medical supervision is the
pre-placement examination — before exposure to organic phosphates.

The need for pre-placement examinations in the interest of protecting the public
is certainly established in the case of motor vehicle operators.

There are 25 million women in the work force in this country today. Pre-place-
ment examinations are important in protecting a pregnant woman from any potential
hazards of occupation.

The examinations can be a valuable tool for case finding (tuberculosis, diabetes,
hypertension, heart disease, early malignant disease and other conditions). Disease
unknown to the examinee may be discovered early. This is a major contribution, in
a preventive sense, of pre-placement examination in industry.

The pre-placement examination can be of great importance in the field of health
education. It has been proven effective in getting employees to listen to the benefits
of health maintenance.

Laws in certain states, such as New Jersey and California, make it prudent to
require a physical examination as a condition of employment. For instance, the un-
employment compensation disability policy in the State of California states that an
employee’s insurance becomes effective on the date he enters employment.

Today we must cope with mental and emotional problems resulting from the
isolation created by automation. The problem of determining the emotional status
of an employee before placement becomes imperative when he is assigned to machinery
representing a capital investment of millions.

The pre-placement examination, as part of an occupational health program, can
be beneficial and valuable to all those concerned. The task of physicians, in and out
of industry, as members of a world community, is to help keep this a human world.
The substitution of a punch card health questionnaire for a good physical examination
by a physician in industry, interested in the problems of people, as well as the
economics of industry, would not further the objective.

Committee on Occupational Health
California Medical Association

Comments and Questions Are Welcomed by the Committee

'This is the fourteenth of a series of articles prepared by the Committee on Occupational Health.

VOL. 97. NO. 6 • DECEMBER 1962

377

APPLICATION
FOR HOTEL
ACCOMMODATIONS

92nd

Annual

Session

CALIFORNIA MEDICAL
ASSOCIATION

March 23* to 27, 1963
LOS ANGELES

*House of Delegates Opening Ses-
sion Saturday evening, March 23;
Scientific Programs begin Sunday
morning, March 24.

INFORMATION

T. Please fill in the form below completely for room accom-
modations at the CMA's 1963 Annual Session. There is only
a limited number of single rooms available. Your choice of
accommodations will be better if your request is for rooms
to be occupied by two or more persons.

2. Your reservation request should include the definite date
and hour of your arrival and departure.

3. Reservations can only be held until 6:00 p.m.

4. All reservations must be made through the CMA
Housing Bureau, Dept. 34, 693 Sutter Street, San
Francisco 2, California.

5. DEADLINE for Housing — March 1, 1963.

HOTEL ROOM RATES*

Single Twin Suites

AMBASSADOR HOTEL

3400 Wilshire Boulevard

Main Building $14.00-$24.00 $1 8.00-$28.00 $40.00-$58.00

Garden Suites $22.00-$34.00 $24.00-$36.00 $54.00-$66.00

CHAPMAN PARK HOTEL

3405 Wilshire Boulevard

Main Building $1 0.00-$1 1 .00 $1 5.00-$l 8.00 $20.00-$28.00

Bungalows (suites) $28.00-$48.00

THE GAYLORD HOTEL

3355 Wilshire Boulevard $1 0.00-$1 2.00 $1 2.00-$1 5.00 $25.00-$35.00

HOTEL CHANCELLOR

3191 West Seventh Street $10.00 $12.00-$14.00 none

SHERATON-WEST

2961 Wilshire Boulevard $1 3.00-$20.00 $1 8.00-$25.00 $34.00

fThe above quoted rates are subject to change.

CALIFORNIA MEDICAL ASSOCIATION— Housing Bureau, Dept. 34

693 Sutter Street

San Francisco 2, California

Single Room $ Twin-Bedded Room $

Small Suite $ Large Suite $ Other Type of Room $

First Choice Hotel Second Choice Hotel

ARRIVING AT HOTEL (Date): Hour: A.M P.M. j Hotel reservations will be held until

Leaving (date) Hour: A.M P.M. 6:00 p.m., unless otherwise notified.

Individual Requesting Reservations — Please print or type:

Name

Address

Are you a CMA Officer? A Delegate? An Alternate?.

County

City and State

378

CALIFORNIA MEDICINE

3n jWemortam

Almada, Albert Alvin, Auburn. Died October 9. 1962, in
Auburn, aged 53. Graduate of Creighton University School
of Medicine, Omaha, Nebraska, 1934. Licensed in California
in 1934. Doctor Almada was a member of t he Placer-Nevada
County Medical Society,

Beers, Reid Lafael, Glendale. Died October 9, 1962, in
Glendale, aged 54, of cerebral thrombosis. Graduate of the
University of Maryland School of Medicine and College of
Physicians and Surgeons, Baltimore, 1936. Licensed in Cali-
fornia in 1938. Doctor Beers was a member of the Los An-
geles County Medical Association.

Boyd, Walter Harrington, Long Beach. Died October
22, 1962, in Long Beach, aged 68, of heart disease. Gradu-
ate of Stanford University School of Medicine, Palo Alto-
San Francisco, 1925. Licensed in California in 1925. Doctor
Boyd was a member of the Los Angeles County Medical
Association.

Byma, Garrett Ralph, San Bernardino. Died October 10,
1962, in Los Angeles, aged 41, after an operation on the
heart. Graduate of Hahnemann Medical College and Hos-
pital of Philadelphia, Pennsylvania, 1952. Licensed in Cali-
fornia in 1953. Doctor Byma was a member of the San Ber-
nardino County Medical Society.

Faulkner, James Lawrence, Red Bluff. Died October 24,
1962, in Red Bluff, aged 66. Graduate of the University of
California School of Medicine, Berkeley-San Francisco,
1926. Licensed in California in 1926. Doctor Faulkner was
a member of the Tehama County Medical Society.

Fowler, Georci-: W. J., Los Gatos. Died October 17, 1962,
in Los Gatos, aged 95. Graduate of the University of Penn-
sylvania School of Medicine, Philadelphia, 1892. Licensed in
California in 1892. Doctor Fowler was a retired member of
the Santa Clara County Medical Society and the California
Medical Association, and an associate member of the Amer-
ican Medical Association.

❖

Gowan, Charles H., Glendale. Died October 15, 1962, in
Glendale, aged 82, of acute myocardial infarction. Graduate
of Rush Medical College, Chicago, Illinois, 1906. Licensed
in California in 1909. Doctor Gowan was a retired member
of the Los Angeles County Medical Association and the
California Medical Association, and an associate member of
the American Medical Association.

Hansen, Arild Edsten, Oakland. Died October 16, 1962,
in Oakland, aged 63, of myocardial infarction. Graduate of
the University of Minnesota Medical School, Minneapolis,
1925. Licensed in California in 1960. Doctor Hansen was a
member of the Alameda-Contra Costa Medical Association.

Hansen, Oluf Steffen, Los Angeles. Died October 30,
1962, in Los Angeles, aged 53, of heart disease. Graduate of
the College of Medical Evangelists, Loma Linda-Los An-

geles, 1937. Licensed in California in 1937. Doctor Hansen
was a member of the Los Angeles County Medical Associa-
tion.

❖

Hauser, Vernon F., Pasadena. Died October 20, 1962, in
Arcadia, aged 57, of a massive coronary. Graduate of Loyola
University School of Medicine, Chicago, Illinois, 1931. Li-
censed in California in 1931. Doctor Hauser was a member
of the Los Angeles County Medical Association.

Jensen, Frederick Grover, Long Beach. Died October
25, 1962, aged 42. Graduate of Hahnemann Medical College
and Hospital in Philadelphia. Pennsylvania, 1946. Licensed
in California in 1950. Doctor Jensen was a member of the
Los Angeles County Medical Association.

Jones, James Earl (J. Earl), Barstow. Died July 28,
1962. in Union City. Tennessee, aged 64, of coronary throm-
bosis. Graduate of Tulane University of Louisiana School of
Medicine, New Orleans, 1922. Licensed in California in
1947. Doctor Jones was a member of the San Bernardino
County Medical Society.

•J*

Kiyslow, Frank Aloysius, San Francisco. Died October
29, 1962. in San Francisco, aged 77. Graduate of Cooper
Medical College, San Francisco, 1906. Licensed in Califor-
nia in 1906. Doctor Kinslow was a retired member of the
San Francisco Medical Society and the California Medical
Association, and an associate member of the American
Medical Association.

Larson, Ernest Eric (E. Eric), Laguna Beach. Died Oc-
tober 22, 1962, in Memphis, Tennessee, aged 72, of coronary
thrombosis. Graduate of Rush Medical College, Chicago,
Illinois. 1920. Licensed in California in 1924. Doctor Larson
was a member of the Orange County Medical Association.

Majors, Ergo Alexander, Bass Lake (Madera Co.).
Died October 20, 1962, at Scottsdale, Arizona, aged 85,
of myocardial infarction due to coronary sclerosis. Gradu-
ate of the University of California School of Medicine,
Berkeley-San Francisco, 1902. Licensed in California in 1902.
Doctor Majors was a member of the Alameda-Contra Costa
Medical Association, a life member of the California
Medical Association, and a member of the American Medi-
cal Association.

O'Grady, William Edward, San Francisco. Died October
27, 1962, in San Francisco, aged 58, of cancer. Graduate of
Creighton University School of Medicine, Omaha, Nebraska,
1930. Licensed in California in 1930. Doctor O'Grady was a
member of the San Francisco Medical Society.

Quirin, Lloyd Frederick, San Francisco. Died October
14, 1962, in Marin County, aged 44, from injuries received
in an automobile crash. Graduate of State University of
Iowa College of Medicine, Iowa City, 1943. Licensed in
California in 1953. Doctor Quirin was a member of the San
Francisco Medical Society.

VOL. 97, NO. 6

DECEMBER 1962

379

Smith, Willard Leroy, Covina. Died September 29. 1962,
in Covina, aged 50, of heart disease. Graduate of New York
University College of Medicine, New York, 1942. Licensed
in California in 1947. Doctor Smith was a member of the
Los Angeles County Medical Association.

❖

Smylie, Robert S., San Diego. Died July 16, 1962, in San
Diego, aged 69, of rheumatic heart disease with aortic steno-
sis. Graduate of Washington University School of Medicine,
St. Louis, Missouri, 1924. Licensed in California in 1930.

Doctor Smylie was a retired member of the San Diego
County Medical Association and the California Medical As-
sociation. and an associate member of the American Medi-
cal Association.

❖

Wood, Walter W., Upland. Died September 19, 1962, in
Upland, aged 78. Graduate of Stanford University School of
Medicine, Palo Alto-San Francisco, 1915. Licensed in Cali-
fornia in 1915. Dr. Wood was a member of the San Ber-
nardino County Medical Society. .

380

CALIFORNIA MEDICINE

INFORMATION

Health Insurance for Senior Citizens

A Report by the Bureau of Research and
Planning, California Medical Association

At the present time older persons in California
can obtain health care benefits under many differ-
ent forms of voluntary health insurance. The various
types of coverage offer a wide scope of benefits
through a wide range of premium costs. The pro-
grams, which are available to older persons on an
individual or group enrollment basis, provide guar-
anteed coverage during the life of the individual.
They do not include the large variety of programs
and policies offered by many insurance and pre-
payment organizations and other health insurance
mechanisms which enable the individual to convert
his policy and become eligible for benefits upon
retirement.

The information in the survey of the California
Medical Association is current as of October 1962:
it does not necessarily list all those programs which
are actually sold in California, since some com-
panies did not respond to the study questionnaire.
The rapid growth of these programs makes it im-
possible to anticipate the many changes that will
he occurring in these programs. Physicians will
find the descriptions of the existing programs help-
ful in informing patients who express an interest in
securing coverage for health care services.

The study by the Bureau of Research and Plan-
ning reveals a variety of approaches and programs,
which are classified as follows:

1. Senior Citizen Hospital-Surgical Group and
Group Approach Plans

These plans, providing hospital and surgical ex-
pense benefits to those 65 and over, are offered by
insurance companies under a mass enrollment tech-
nique. Enrollment can either be made during speci-
fied time periods on a statewide basis or all year
round by personal application on reaching age 65.

Offering hospital room-and-board benefits up to
$10 a day, these plans pay benefits from 31 to 140
days during hospital confinement. Additional bene-
fits are paid to help meet other extra hospital ex-
penses such as drugs, laboratory fees, surgical

A recent report by the Health Insurance Insti-
tute indicates that, as of October 1962, 55 per cent
of tlie total non-institutionalized aged population in
the United States were enrolled in some form of
voluntary health insurance. More than 200 organi-
zations, nationally, provide coverage for the more
than nine million senior citizens.

A recent survey by the California Medical Asso-
ciation’s Bureau of Research and Planning reveals
that 70 insurance and prepayment organizations of-
fer 140 programs for such coverage on a guaran-
teed renewable basis in the State of California.

The Bureau’s survey did not attempt to secure
the number of aged enrolled, since its objective
was to determine the nature and the number of the
programs available.

The accompanying text describes the variety of
plans available to the aged in California on a guar-
anteed renewable basis.

charges, and costs of care in nursing homes. Surgi-
cal allowances can range up to $225.

Applicants are eligible irrespective of their past
medical histories and without medical examinations.
Generally, plans require the newly insured person
with a pre-existing health condition to wrait six
months before benefits are available for that partic-
ular condition.

Protection of these plans cannot be terminated
for any individual policyholder — only for state
residents as a group. Similarly, premium charges
can only be adjusted for an entire state group — not
on an individual policyholder basis.

Selected yearly premiums for a male, age 65,
range from $78.00 to $108.00.

2. Senior Citizen Lifetime Guaranteed Renewable
Hospital-Surgical Expense Plans

Persons past 60, who desire hospital and/or
surgical expense protection on a guaranteed renew-
able individual or family basis can choose from a
multitude of insurance companies’ policies.

These policies generally offer hospital room-and-
board benefits from $5 to $30 a day, with a wide
selection of additional benefits for extra hospital
expenses. Surgical allowances under these policies
can range up to $600. Coverage for Miscellaneous
Extras range from $100 to $1,000. Many of these
policies include extra benefits such as ambulance
service, out-patient surgery, and in-hospital medical
care.

As with other guaranteed renewable lifetime
policies, the insured person only can terminate the
policy and the insurance company can only adjust
premiums by policyholder class.

Benefits are paid for periods from 21 to 365
days. Entrance ages for applicants are 61 and over.

Selected yearly premiums for a male, age 65,
range from $86.60 to $244.75

VOL. 97. NO. 6 • DECEMBER 1962

381

3. Weekly or Daily Benefit Senior Citizen Hospital
Expense Plans — Group Approach and Guaran-
teed Renewable for Life

These policies pay a stated dollar allowance, rang-
ing from $25 to $210 ($300 if surgery is involved)
for a maximum number of weeks while the insured
person is under hospital care. For persons over 65,
the range of benefit weeks is from 8 to 50. Benefits
provided are designed to meet the added expenses
of the policyholder’s hospitalization.

Under a group approach plan, persons 65 and
over can make application for this protection during
specified enrollment periods. The plan is issued
regardless of the applicant’s health condition, and
without medical examination.

Premiums can be modified only for the entire
state group, and protection cannot he terminated
for an individual policyholder — oidy for the group
as a whole. This particular group-type plan is issued
as a supplement to a basic “Senior Security” health
insurance plan.

Under guaranteed renewable policies which pro-
vide benefits for lifetime, the insured person has the
sole right of policy termination. The insurance
company can adjust premiums only on a policy-
holder class basis.

Selected yearly premiums for a male, age 65,
range from $54.00 to $168.50.

4. Senior Citizen Catastrophic Expense Plans (Ma-
jor Hospital or Medical )

Under these policies, persons 65 and over can
choose benefits toward the expenses of prolonged
hospital and/or medical care. Each of these plans
has a “deductible” feature which the insured person
must satisfy before policy benefits commence. Some
have a sharing of expenses (co-insurance) by the
policyholder above the specified “deductible.”

All the plans in the survey have a lifetime guaran-
tee. Requirements for enrollment vary according to
whether a group or individual insurance technique
is used. Dependent upon the particular plan, there
may or may not be a health requirement for appli-
cation.

Benefits under these plans for hospital and/or
medical catastrophic expenses can reach a maximum
of $10,000.

Selected yearly premiums for a male, age 65,
range from $55.00 to $211.75.

5. Additional Hospital-Surgical Expense Plans (Bas-
ic and Major) Providing Continuation of Pro-
tection Regardless of Changes in Health

These plans, covering both those over and under
65 years of age, will guarantee the continuation of
their protection without regard to a change in the

health of the policyholder. As determined in the
survey, they cover basic hospital, medical and surgi-
cal charges as well as major or catastrophic hospital
and medical expenses.

The range of benefits for basic policies is from
$5 to $30 toward daily hospital room-and-board
charges. Additional benefits are paid to help meet
other extra hospital expenses, and range from $50
to $1,000. Extra benefits such as nursing home care,
and in-hospital medical are provided. Surgical bene-
fits range up to $750. Policies will provide benefits
from 60 to 1,000 days for each illness or injury.

Catastrophic expense policies for hospital and/or
medical expenses of this type have maximum bene-
fits from $5,000 to $10,000. Deductible amounts
vary from $25 to $1,000.

Under catastrophic hospital and major medical
expense policies, the insured person commonly pays
20% to 25% of expenses above the “deductible.”
Selected yearly premiums for a male, age 59,
range from $52.70 to $83.00 for the basic plans,
from $40.00 to $83.00 for catastrophic hospital
plan, and from $83.00 to $91.00 for the major
medical plan.

6. Guaranteed Renewable Lifetime Hospital-Surgi-
cal Expense Plans — Issued to Persons Under 65
Years of Age

These policies provide protection against hospital
and surgical expense for the lifetime of the persons
insured under them. The protection of these policies
can only he terminated by the insured person
through non-payment of the premium. The insur-
ance company reserves the right to adjust the policy
premium by policyholder class — not on an individ-
ual basis. Some of these plans are available with
hospital benefits only and, as a result, have lower
premium charges. Hospital room-and-board benefits
range from $5 to $30 per day, for duration of stay
ranging from 31 to 365 days.

Extra benefits included in each plan for same
premium include ambulance service, out-patient
surgery and emergency accident care; optional
benefits can be added for an additional premium.
Additional miscellaneous extras to help meet cost
of hospitalization range from $50 to $1,250; surgi-
cal schedules range from $150 to $700.

Some guaranteed renewable lifetime hospital-
surgical expense policies require the insured person
to pay a small initial amount (called “deductible”)
of his hospital-surgical expenses before policy bene-
fits start. Many of these policies, however, require
no “deductible” amount or make it an optional
choice of the insured person — in such cases, pre-
miums are calculated according to the method
selected.

382

CALIFORNIA MEDICINE

Some guaranteed policies continue the same bene-
fits throughout the lifetime of the insured person;
others reduce benefits at 65 years of age or provide
a fixed amount of benefits above 65 for lifetime.
Many policies provide dividends which help reduce
their yearly premium charges.

Premium charges of health insurance policies
are determined by many factors: the applicant’s
age, sex, commonly the number of family members
included, and the amount of benefits chosen.

Selected yearly premiums for a male, age 55,
range from $84.80 to $233.60.

7. Guaranteed Renewable Lifetime Hospital-Surgi-
cal Expense Plans Fully Paid-up at 65

The unique feature of these guaranteed renewable
lifetime hospital and surgical expense policies is
that they become fully paid-up when the policy-
holder reaches 65 with their benefits continuing as
formerly provided or on a reduced basis for the
insured person’s lifetime.

As with other guaranteed renewable policies, the
insured person has the sole right of terminating the
policy, with the insurance company reserving the
right to adjust the policy’s premium according to
policyholder class.

These policies provide benefits, ranging from
$5 to $25, toward hospital daily room-and-board
charges with additional benefits for extra hospital
expenses ranging from $75.00 to $480.00, and sur-
gical operations with surgical schedules ranging
from $100 to $600. Policy benefits are provided
for as long as 365 days before age 65, with reduced
benefits and benefit periods after the policyholder
reaches his 65th birthday. Extra benefits include
coverage for such services as emergency accident
care, out-patient surgery, and ambulance service.

Many of these fully paid-up at 65 policies offer
additional benefits for out-patient surgery, emer-
gency accidents, and in-hospital physician visits.
Some of these policies have optional “deductible”
amounts which can be selected by the applicant.
The maximum age range for applicants is between
55 and 61 years.

Selected yearly premiums for a male, age 35,
range from $80.64 to $188.60.

8. Guaranteed Reneivable Major Medical Plans with

Lifetime Coverage or Extended Benefits Beyond

These guaranteed renewable policies provide ben-
efits toward all normal medical expenses, both in-
and-out of the hospital, resulting from catastrophic
or prolonged illness or injury. They all have “de-
ductible” features which specify the amount of
expenses that the insured person must first meet
before policy benefits begin.

These policies usually provide benefits of 75%-
80% toward medical charges above the “deductible”
amount and up to the maximum benefits provided-
ranging from $5,000 to $24,000. Some of these
policies have specified benefit amounts according
to particular types of medical expenses.

Under these policies, too, the insured person has
sole right of termination, with the insurance com-
pany reserving the right to adjust premiums by
policyholder class.

Benefits under these policies may be continued
after 65 as formerly provided by the policy, or
on a reduced basis for the insured person’s lifetime.

Selected yearly premiums for a male, age 45,
range from $40.45 to $91.96.

9. California Physicians’ Service (Blue Shield)

The three programs for persons 65 and over of
the California Physicians’ Service are briefly de-
scribed as follows: Plans I and II are available on
a year round basis. The third program, the “Senior
Citizens Program” is available during specified
enrollment periods. Plans I and II provide paid-in-
full physicians’ service for annual family incomes
of up to $7,200. The income level for full payment
of professional services of the Senior Citizen Pro-
gram is $6,000. There is a registration fee of $5
for each program. Hospital benefits are for 31 days
per year, with payments for room and board as
70% of a three-bed ward rate up to $18 per day.

Services of surgical assistants, anesthetists, and
surgical consultants are paid in full. Diagnostic
x-ray and laboratory charges are paid from $50 per
year, in or out-of-hospital, to 70% of all charges.
Under Plan II, 50 home and office physician visits
are covered, after an out-patient deductible of $100
per year. Coverage for hospital extras ranges ac-
cording to plan — from full cost of certain extras,
to 70 per cent of charges. Waiting periods for pre-
existing conditions range from 6 to 12 months.

Selected yearly premiums at age 65 range from
$166.20 to $236.40.

10. Blue Cross Plans Offered by:

1 — Hospital Service of California

2 — Hospital Service of Southern California

Blue Cross Senior Citizen Health Plan

The Blue Cross Senior Citizen Health Plan for
California residents of 65 years or older offers a
choice of two programs — 31 hospital days and 70
hospital days — for each calendar year. It is available
from the two Blue Cross Plans.

Both programs include hospital, medical, emer-
gency accident, and surgical benefits. In addition,
the 70-day program offers, after six months’ mem-
bership, care in a skilled nursing facility upon

VOL. 97. NO. 6 • DECEMBER 1962

383

discharge from a hospital and the services of a
registered visiting nurse in the home.

While the Plan pays a minimum of $18 a day,
there is no maximum payment. Eighty per cent of
most hospital expenses are covered, regardless of
amount.

Eligibility for the Plan is not restricted by an
upper age limit or a health statement. Pre-existing
conditions are covered after six consecutive months

of membership. Enrollment in the Blue Cross Senior
Citizen Health Plan is open during specified periods
during the year.

In addition to this plan, the Hospital Service of
Southern California has another plan for older
persons, which is open on a year round basis.

Selected yearly premiums at age 65 and over
range from $105.40 to $189.60.

California Medical Association, 693 Sutter Street, San Francisco 2.

The following listing contains the names of the organizations which responded to the
survey, and which offer one or more of the programs in the ten categories described above.

Insurance and Prepayment Organizations in California with Programs for Coverage for Older Persons

Aetna Life Insurance Company

All American Life and Casualty Company

American Association of Retired Persons Insurance Plan

American Casualty Company of Reading

American Motorist Insurance Company

American National Insurance Company

Bankers Life Company

Beneficial Standard Life Insurance Company
Benefit Trust Life Insurance Company (formerly Benefit
Association of Railway Employees)

Business Men’s Assurance Company of America
California Physicians’ Service (Blue Shield)

California Western-States Life Insurance Company

Capitol Life Insurance Company

Colonial Life Insurance Company of America

Connecticut General Life Insurance Company

Continental Assurance Company

Continental Casualty Company

Federal Mutual Insurance Company

Fireman’s Fund Insurance Company

General American Life Insurance Company

Girardian Insurance Company

Great Southern Life Insurance Company

Great-West Life Assurance Company

Guardian Life Insurance Company of America

Hanover Insurance Company

Hospital Service of California (Blue Cross)

Hospital Service of Southern California (Blue Cross)
Insurance Company of North America
John Hancock Mutual Life Insurance Company
Life Insurance Company of North America
Lincoln National Life Insurance Company
Loyal Protective Life Insurance Company
Lumbermens Mutual Casualty Company
Maccabees Mutual Life Insurance Company
Massachusetts Protective Association, Inc.

Metropolitan Life Insurance Company

Midland Mutual Life Insurance Company
Midland National Life Insurance Company
Ministers Life and Casualty Union
Monarch Life Insurance Company
Mutual Life Insurance Company of New York
Mutual of Omaha
National Travelers Life Company
New York Life Insurance Company
North American Life and Casualty Company
Northwestern Life Insurance Company
Northwestern National Life Insurance Company of
Minneapolis

Occidental Life Insurance Company of California

Ohio State Life Insurance Company

Old Line Life Insurance Company of America

Pacific Mutual Life Insurance Company

Pacific National Life Assurance Company

Paul Revere Life Insurance Company

Pioneer Mutual Life Insurance Company

Provident Mutual Life Insurance Company of Philadelphia

Prudential Insurance Company of America

Republic National Life Insurance Company

Reserve Life Insurance Company

St. Paul Fire & Marine Insurance Company

Springfield Insurance Company

Standard Insurance Company

State Mutual Life Assurance Company of America
Travelers Insurance Company
Union Mutual Life Insurance Company
Washington National Insurance Company
West Coast Life Insurance Company
Western Life Insurance ( See St. Paul Fire & Marine
Insurance Company)

Westland Life Insurance Company
AVoodmen Accident and Life Company
World Insurance Company

All or part of the contents of this Socio-Economic Report may be reproduced without permission. Please credit the
Bureau of Research and Planning, California Medical Association.

NEWS & NOTES

NATIONAL • STATE • COUNTY

ALAMEDA

Dr. Harold K ay was installed as president of the
Alameda-Contra Costa Medical Association at the annual
meeting of the organization in November. Other new
officers are Dr. Paul Cronenwett, vice president, and Dr.
Carl Goetsch. secretary.

LOS ANGELES

Appointment of Dr. J. Edward Beck, of Detroit,
as professor and chairman of the department of medicine
at the California College of Medicine, has been an-
nounced by Dr. Benjamin B. Wells, dean.

Dr. Berk, who begins his new duties January 1, is at
present clinical professor of medicine at Wayne State
University College of Medicine. He also is visiting lecturer
in medicine, Graduate School of Medicine, University of
Pennsylvania.

The two-year resident training program in child psy-
chiatry at the Reiss-Davis Clinic for Child Guidance,
Los Angeles, has been accredited by the American Medi-
cal Association. The accreditation is the first to an in-
dependent clinic in the Western section of the United
States that is not affiliated with either a medical school or
hospital.

MARIN

Dr. C. Ray Leininger, San Rafael, was installed as
president of the Marin Medical Society, succeeding Dr,
Joseph J. Arons, also of San Rafael, at the Society’s
annual meeting early last month. Dr. Calvin Plumhof,
Kentfield, was elected president-elect.

Dr. Ivan J. Miller, Sausalito, was installed as president
of the Radiological Society of North America at the or-
ganization’s recent forty-eighth annual meeting, held in
Chicago.

Dr. Miller is currently president of the California Radio-
logical Society.

SANTA CLARA

The Stanford University School of Medicine has added
two new associate professors to the faculty of its depart-
ment of psychiatry. They are Dr. William C. Dement and
Dr. Herbert Leiderman. Dr. Dement, whose appointment
began December 1, has done extensive research on the
functioning of the mind during sleep and dreaming. He
is now associated with the Department of Psychiatry,
Mount Sinai Hospital, New York.

Dr. Leiderman, currently an associate in psychiatry at
Harvard Medical School and a career investigator for the
U. S. Public Health Service, has carried out clinical and
laboratory investigations on sensory deprivation. His ap-
pointment becomes effective June 1, 1963.

GENERAL

Results of research by medical students along the
entire Pacific Coast will be reported at the first West
Coast Medical Student Research Day to be held February
16 at the University of Washington.

The Medical Student Research Society at Washington
has invited all Coast medical schools to send representatives
to present papers. It is planned to have some 60 presenta-
tions. Acceptances have already come from the University
of California at Los Angeles, and the University of British
Columbia.

* * *

The Second Mexican Congress of Dermatology is

to be held in Guadalajara, Jalisco, April 16-20, 1963. The
preliminary program lists a wide range of subjects — Physiol-
ogy and Biochemistry of the Skin, Immunology in Der-
matology, Epidemiology of Cutaneous Diseases, Psychoder-
matoses, Tropical Dermatology, Pigmentation, Occupational
Dermatoses, Cutaneous Oncology and Plastic Surgery.

Further information may be obtained from either of the
two California delegates to the Congress — Dr. Paul Fasal,
706 D Street, San Rafael, and Dr. Maximilian E. Ober-
*mayer, 3875 Wilshire Boulevard, Los Angeles 5.

District hospital trustees and administrators participat-
ing in the recent annual meeting of the Association of Cali-
fornia Hospital Districts, held in Santa Barbara, unani-
mously endorsed a recommendation to their membership
that the Guiding Principles for Physician-Hospital
Relations be adopted and implemented.

It was resolved that “this association go on record as
recommending to its members that each District (1) adopt
the Guiding Principles for the Physician-Hospital Relation
Program and (2) that each District join with its medical
staff in requesting an examination by the California Medical
Association under that program.”

❖ >e S-

Local medical societies and heart association chapters are
urged to develop plans for proper training of rescue per-
sonnel in closed chest cardiac resuscitation in a joint
statement issued by the California Medical Association and
the California Heart Association.

In a covering letter to presidents of component medical
societies Dr. Harold Kay, chairman of the California Medi-
cal Association Committee on Allied Health Agencies, said
that each society is urged to have its membership in-
formed as to the proper closed chest techniques. Doc-
tors then are encouraged to instruct firemen, policemen and
members of emergency rescue squads in the procedure, he
said.

The statement included the suggestion that local joint
committees determine the guidelines for training appro-
priate personnel and for discouraging training of in-
appropriate personnel.

VOL. 97. NO. 6

DECEMBER 1962

385

THE RELUCTANT SURGEON— A Biography of John
Hunter — John Kohler. Doubleday & Company, Inc., 575
Madison Avenue, New York 22, New York, I960. 359 pages,
$4.95.

John Hunter was born on February 13, 1728, at East Kil-
bride in Lanarkshire, Scotland, the son of a landed propri-
etor of modest means. Written off by his teachers as an idle,
surly dullard, irredeemable by punishment or reward, John
terminated his formal schooling at age 13. When he quit he
could barely write coherent English, and had acquired a
permanent distaste for scholastic halls.

For a time he managed the farm plantings and animals,
and was engaged for a brief period in the trade of cabinet
making. In desperation his anxious mother finally sent him
to London to help his ten-year-older brother William in his
School of Anatomy and Surgery. A fascinating but dis-
quieting account is given of enterprising body snatchers
who supplied William with stolen bodies for dissection.
Those were palmy days for sextons. The bereaved paid them
generously to keep out the “resurrectionists” (body snatch-
ers) and the resurrectionists paid them still better to let
them in. Bands of ruffians were formed for the purpose of
snatching bodies, fighting each other in their fiendish and
ghoulish activity. When the demand for bodies became
greater than the usual supply (hanged criminals), murders
were perpetrated for the sole purpose of providing bodies.
(Burke and Hare in Edinburgh; Bishop, Williams, and
May in London.)

The public, of course, was incensed. William Hunter’s
school was repeatedly stoned. British law favored the resur-
rectionists. Nobody owned a dead body, and therefore tak-
ing one could not be a theft. Stealing five shillings was
punishable by death, a body snatcher was fined or suffered
a public whipping! William needed up to 100 bodies a year
for his school. John was delegated by his brother to handle
the negotiations with the body snatchers. It is said John
himself snatched bodies. One of William’s master works,
“The Anatomy of a Gravid Uterus,” was based on dissec-
tions of 400 bodies over 23 years’ time. Not until Parliament
in 1821 passed the Anatomy Act which provided that all un-
claimed bodies be distributed among the medical schools
was body snatching brought to an inglorious end.

Soon after his arrival in London, John became a pupil of
William Cheselden, the lithotomist of great fame, and the
author of “The Anatomy of the Human Body,” which was
not superseded for 100 years. From this prodigy John
learned the fundamentals of surgery. An interesting ac-
count is given of Cheselden’s technique of cutting for stone.
Upon Cheselden’s death in 1751, John continued his surgical
studies under Percival Pott at St. Bartholomew’s Hospital.
From him John learned the restorative powers of nature,
and the value of simplicity in surgery, in medication, and
in bandaging.

In the summer of 1754 John was admitted as a surgeon’s
pupil to St. George’s Hospital, the institution with which
he was associated for the rest of his life. John, at the sug-

386

gestion of William, conducted some fundamental studies of
the reproductive system in man by injecting the vas deferens
with mercury, thus demonstrating the seminiferous tubules.
The descent of the testes inlo the scrotum was also de-
scribed accurately by John. Studies on the lymphatic sys-
tem by the two brothers achieved a discovery ranking not
far below Harvey’s circulation of the blood.

John’s first patient (1752) was suffering from a gonor-
rheal stricture, for whose treatment he designed special in-
struments resulting in its cure through direct caustic
applications.

In 1754 William persuaded John to enter Oxford Univer-
sity, hoping he would acquire some cultural polish. Within
a few weeks he was back at St. George’s where he remained
five months as house surgeon, returning then to William’s
School of Anatomy. This volume is to a great extent a biog-
raphy also of William Hunter, whose extraordinary career
and many triumphs are recorded almost as faithfully as
John’s. Interestingly described are William’s fantastic suc-
cesses as a man midwife, his appointment as accoucheur to
the Queen and to many noble ladies, his prosperous School
of Anatomy and Surgery, where his lectures were closely
attended not only by medical students and doctors, but also
by such celebrities as Adam Smith, Edmund Burke, Wal-
pole, Samuel Johnson, Benjamin Franklin, Joshua Reynolds,
and Thomas Gainsborough.

Disappointing and disturbing, therefore, after years of
collaboration in important studies and in the conduct of
the School of Anatomy, is the serious rift which occurred
between the brothers when John returned from a stint of
three years with the Army. During these years he made dis-
sections of over 200 animals, correlating structure and func-
tion, demonstrated that fish can hear, ascertained how eels
propagate themselves, and established rules governing the
care of penetrating wounds, which he taught should be let
alone until evidence of inflammation appeared.

On John’s return from the Army, William failed to re-
instate him as assistant in his school, leaving him with only
his pension from the Army to sustain him. In need of other
sources of income he became the surgeon-consultant of a
prominent family of “tooth drawers,” as dentists of the
period were known. From this experience emerged the first
scientific treatise on dentistry in the English language, his
two-volume “Natural History of the Teeth,” which included
a comparative study of every species in the animal kingdom
that grows teeth.

In the meantime he became engaged to Anne, the lovely
and accomplished daughter of a Dr. Home, but he could not
marry her, and for a reason he could not tell her. He had
embarked (May 22, 1767) on a three-year study of what
would happen to him if he infected himself with the pus
excreted from the sore of a venereal patient, infected, so
he thought, with gonorrhea. The unexpected happened — he
contracted both syphilis and gonorrhea, the progression of
which he followed closely, studying the effect of mercury

CALIFORNIA MEDICINE

upon the waxing and waning of an enlarged gland in his
groin! When finally he had observed and had recorded every
symptom, some due to gonorrhea, some due to syphilis, he
applied the maximum dosage of mercury — and married Anne
July 22, 1771.

The author provides an entertaining account of the
Hunter household — Anne’s salon attended by such promi-
nent people as Walpole, Goldsmith, Lady Byron, and
Haydn, while John was concerned with important or un-
usual patients and visitors to London who interested him
more than any Peer, e.g., a family of five Eskimos, the first
ever to set foot in England, were invited by him to dinner!

In 1767 the Royal Society admitted John as a Fellow,
three months before the prominent and successful William!
This was followed by his becoming a member of the Corpo-
ration of Surgeons and the appointment to the staff of St.
George’s Hospital, where students favored his ward walks
and where he taught that to operate is to concede inade-
quacy. Said he: “No surgeon should approach the victim
of his operation without a sacred dread and reluctance.”
“Never perform, an operation on another person which un-
der similar circumstances you would not have performed
upon yourself.”

He taught the interdependence of mind, emotions, and
body, and was aware of the psychic factors in disease and
the power of autosuggestion. “Anxiety is expressive of the
union of two passions, desire and fear.”

John soon found himself teaching students from many
lands. Moreover, George III appointed him Surgeon Ex-
traordinary and sent some of his eight sons for instruction
in Anatomy and Medicine, much to John’s displeasure. Ed-
ward Jenner, a clergyman’s son, became his devoted and
admiring disciple. Together they pondered on the natural
immunity to disease, why those who survived smallpox were
seldom reinfected. John recognized in Jenner a capacity for
creative research and a curiosity as omnivorous as his own.
“ Don’t think,” he would say when Jenner stopped to weigh
the feasibility of some thorny experiment— “Try it.” In
1798 Jenner published his “Inquiry into the Cause and Ef-
fect of the Variolae Vaccinae.”

Some of the illustrious Americans who had been at one
time students of either William or John or both were: Rich-
ard Bayley who became the first Professor of Anatomy and
Surgery at Columbia College; Philip Wright Post, his son-
in-law, who became Professor of Surgery and introduced
John’s operation for popliteal aneurysm in America; Ben-
jamin Waterhouse who became the first Professor of the
Theory and Practice of Physic at Harvard; although Har-
vard later sacked him, he introduced a batch of trustworthy
smallpox vaccine from Jenner’s stock into America; John
Morgan who founded with William Shippen the first medi-
cal school in America at the University of Pennsylvania, be-
came its first Professor of Physical Theory and Practice,
and was the first to advise specialization in Medicine; Philip
Syng Physick, physician to Andrew Jackson, who was later
hailed as the Father of American Surgery.

One morning in 1772, John, aged 44, was struck by a
spasm of chest pain of such violence that he could neither
stand nor lie down. Laudanum brought no relief. His ashen
face and white lips were those of a corpse and he had a
sense of imminent death. He felt his pulse but detected no
beat. Forty-five minutes passed before relief set in. Three
years later the second attack occurred which left him greatly
enfeebled. In this state he was seen by Jenner who diag-
nosed his trouble as “angina pectoris” — a term coined by
Heberden — of which he had seen two cases, both of which
had been studied after death, disclosing a “thickened coro-
nary” in one, and in the second “a firm fleshy tube within
the coronary artery with ossification dispersed through it.”

For the rest of John’s life, the least exertion, physical or
emotional, was apt to induce spasms ending in unconscious-
ness. “My life is at the mercy of any rogue who chooses to
provoke me.” But the disease did not injure the major area
of his cerebral cortex— the seat of intellectual function — for
he retained to the end his powers of observation and rea-
soning. The periods of his greatest debility were among his
most creative!

Indeed his activities continued unabated. In 1783, he ac-
quired a two-house mansion in Leicester Square, a few
houses removed from the home of Sir Joshua Reynolds, who
gave the gayest parties in London. He soon added a third
building, containing a lecture theater on the lower floor,
and a long lofty galleried hall on the upper floor where
John installed his anatomical collection. This was to become
known ever after as the Hunterian Museum and later was
acquired by the Royal College of Surgeons with a grant
from the Crown. Here he integrated within a single the-
matic frame the manifold aspects of comparative anatomy,
a mass of animal and vegetative preparations, thousands
upon thousands, including 6 whales; 5,000 jars of wet spec-
imens and a colossal number of specimens from crocodiles’
teeth to the battery of an electric eel; the full hive economy
of the honey bee; and a large collection of monstrosities,
the most famous being a giant 8 feet, 6 inches tall (the ac-
quisition of which provides a fascinating chapter) — all to
elaborate the grand motif: What distinguishes life from
non-life in both individual and species is an innate power of
self-maintenance, and by it are produced the endless adap-
tive mutations of structure.

In addition, John maintained a second great establish-
ment at Earl’s Court — 52 acres in the country where he was
perpetually conducting experiments on dormice, hedgehogs,
rabbits, bats, birds, mice, pigs, lions, tigers and leopards,
trying to answer such questions as: why plants grow up-
ward; does coloration play a part in the sexual excitement
of the zebra (it does) ; how do bones grow; do ovaries
wear out by repeated propagation (they do in pigs) ; where
do swallows go in winter; can the formation of pearls be
artificially stimulated (they can) ; how do pigeons give
“milk” to their young; what is the pitch of the sound of
swarming bees (treble A above middle C) !

Here John worked incessantly framing strategems to un-
riddle the riddles that seethed in his brain. Close to the
spirit of pure science, he often pursued an idea without
concerning himself about its practical potentialities. Never-
theless, there was hardly a major surgical development dur-
ing the next two generations that had not germinated in the
Hunterian seedbed.

Meanwhile the rift between William and John mounted.
William resented John’s overshadowing renown, the magni-
tude of his establishments, and the multiplicity of his works.
Lamentably, the Royal Society was treated to a brotherly
squabble as to which one had discovered the structure of
the placenta. The Society looked away in disgust and em-
barrassment and refused to arbitrate the quarrel.

One of William’s last redeeming acts was to educate his
sister Dorothea’s son, Matthew, who later became a noted
and popular surgeon and teacher in his own School of Sur-
gery and Anatomy. William finished his last of thirty-odd
books and monographs in 1783, a scanty output compared
with John’s, but of high quality. He died on March 30, 1783,
of a stroke (without reconciliation with John).

During the spring of 1785 John suffered his worst “heart”
attack in years. But again he revived and pursued one of the
most rigorous inquiries of his career: his discovery of col-
lateral circulation following ligation of the carotid artery
in a young stag with growing antlers, which caused the
affected antler to grow cold and its growth to stop. However,

VOL. 97, NO. 6

DECEMBER 1962

387

the antler soon became warm again and resumed growing,
due as Hunter demonstrated to a well-functioning collateral
circulation.

Four months later John was confronted with a popliteal
aneurysm of great size, for which he applied two ligatures
in “Hunter’s Canal,” instead of just above the aneurysm as
in Anel’s operation, and two ligatures below the aneurysm.
The patient recovered without gangrene due to the col-
lateral circulation around the knee which John had postu-
lated on the basis of his experiments on the deer.
Subsequently John limited the operation to ligation in the
“adductor canal” — his fourth patient lived fifty more years.

Another study was published as a “Treatise on Venereal
Disease,” the product of 18 years’ investigation, but inaccu-
rate since it was based on the supposition that he had in-
oculated himself with gonorrhea, whereas actually he had
inoculated himself with both syphilis and gonorrhea.

John’s practice at this time was extensive but not remu-
nerative. In his waiting room the Duke of Richmond might
find himself sitting between some grimy-handed coke heaver
and his own haberdasher. John adjusted his fees to the pa-
tient’s pocketbook. “You are the best judge of your own
circumstances, and it is far from my wish to deprive you
of the comforts of life.” He accepted no pay from clergy-
men, authors, or artists. He treated workingmen first, say-
ing: “You have no time to spare,” adding with a scornful
glance at the group of fidgeting noblemen: “Most of these
can wait, as they have ‘vurra’ little to do when they go
home.”

His patients included the Boswell family, George Byron
for his club feet, the Duke of Atholl’s son, Thomas Gains-
borough, Reynolds, and Benjamin Franklin. But not all was
to his liking or to his benefit. He had made many enemies
by his candor, his brusqueness and his presumptuous criti-
cism of fellow surgeons.

On October 16, 1793, at a board meeting of St. George’s
Hospital, an insolent remark was made by a fellow board
member, which so angered John that while struggling to
control his temper he staggered into the adjoining room,
fell senseless, and died that afternoon. Necropsy revealed
widespread arteriosclerosis, with an aneurysmal dilatation
of the ascending aorta, the wall of which was studded with
opaque white spots, a picture consistent with the terminal
ravages of syphilis. He was denied burial in Westminster
Abbey and was interred in St. Martin’s-in-the-Fields on
Trafalgar Square.

One paper hailed him as “the first surgeon in the world,”
another as “the greatest philosophical surgeon and the
greatest comparative anatomist which the useful art that he
practised had ever known.”

On March 28, 1859, 66 years later, a young and ardent
admirer of Hunter and an Army surgeon, Francis Trevelyan
Buckland, painstakingly undertook the laborious task of
identifying his leaden coffin stored at St. Martin’s-in-the-
Fields in a vault containing 3,259 other coffins. (Hunter’s
coffin was the last but one to be inspected!) Buckland pre-
vailed upon the Government to transfer Hunter’s remains
to Westminster Abbey to lie beside those of Ben Jonson.

“The Royal College of Surgeons of England has placed
this tablet on the grave of Hunter to record admiration of
his genius as a gifted interpreter of the Divine power and
wisdom at work in the laws of organic life, and its grateful
veneration for his services to mankind as the founder of
scientific surgery.”

Finally, the author records with outraged feeling the dis-
graceful plagiarisms perpetrated by Everard Home, Hunter’s
brother-in-law, of many of Hunter’s unpublished notes, and
his burning of over 30 volumes of John’s notes relating to
the collections in the Museum. This heinous act was dis-

closed to the Board of Curators of the Museum created by
the Royal College of Surgeons by one William Clift, a one-
time servant and devoted admirer of John Hunter, who
continued as Curator of the Museum for 49 years after
Hunter’s death. Everard Home escaped punishment, but
most of his colleagues viewed him with contempt. He died
in his seventy-seventh year, a victim of gout and excessive
drinking.

A glaring defect in this fascinating and well-written ac-
count of two of England’s greatest surgeons and scientists
is the absence of a single illustration, not even a reproduc-
tion of Sir Joshua Reynolds’ masterly portrait of John
Hunter, caught in a deep reverie, “when the body loses con-
sciousness of its own existence.” When the Swiss theologian,
Johann Lavater, saw the portrait he exclaimed: “That man
thinks for himself.”

This brief review gives a very inadequate concept of the
monumental and fascinating information this biography con-
tains of the life, customs, and social conditions contempo-
rary with Hunter’s time, both in Scotland and England.
The description of a country doctor’s experience with “An-
gina Pectoris” is most valuable. Contemporary medical
practices in America are also depicted in instructive man-
ner. The book should be required “relaxation” reading for
every medical student on his long and arduous journey to
the practice of Medicine.

Emile Holman, M.D.

❖ * *

A TEXTBOOK OF OBSTETRICS— Duncan E. Reid.
M.D., William Lambert Richardson Professor of Obstet-
rics, and Head of the Department of Obstetrics and Gyne-
cology, Harvard University Medical School: Chief of Staff,
Boston Lying-In Hospital. W. B. Saunders Company,
Philadelphia, Pa., 1962. 1087 pages, $18.50.

When a new, full sized obstetrical textbook enters the
stiff competition for general acceptance by teachers, students
and practitioners, one always wonders what motivated the
author to undertake what must have seemed at times almost
a staggering task. Reid has asked himself this question in
his preface, and by way of answering it he has cited four
purposes his book is intended to fulfill. Firstly he wished
to relate advances in our knowledge of birth trauma, con-
genital malformations, prematurity, and poor reproductive
performance in general to the immediate clinical situation.
It is suggested that the renewed interest in human repro-
ductive physiology may shortly lead to solutions for these
distressing and widespread problems. Secondly, the author
aims to promote the highest quality of patient care by pre-
senting the process of human reproduction in the simplest
of terms for those engaged primarily in supplying the vast
demand for medical services. Thirdly, he set out to describe
and emphasize the basic principles of good obstetrical man-
agement, with particular reference to currently accepted
practices in the Boston Lying-in Hospital and Harvard Med-
ical School, and lastly to relate the process of human repro-
duction to the general framework of biology and medicine
as a whole.

In the main I believe he has succeeded admirably in ful-
filling these objectives. The book is beautifully written and
it flows along easily, perhaps because statistics, particularly
the kind dealing with various series of cases recorded in the
literature, have been omitted wherever possible. The author
rightly points out that percentages may be of interest in
certain settings but tend to lose their significance when
one faces the treatment of an individual patient. There is
less than the usual didactic emphasis on the mechanistic as-
pects of labor and delivery, but these areas have not by
any means been slighted. Throughout the volume one finds
much of Reid’s personal philosophy about obstetric mat-
ters, and while one may perhaps not choose to embrace all

388

CALIFORNIA MEDICINE

his beliefs, the arguments in controversial areas are most
lucidly and thoughtfully presented. The author’s voice comes
alive clearly and forcefully from every page.

Experts in various fields afforded help with some of the
chapters. The late Thomas Goethals provided a chapter on
breeches, Kurt Benirschke one on multiple pregnancy,
Claude Villee a short piece on human genetics. Blood group-
ing problems and erythroblastosis have been covered by
F. H. Allen, Jr. and a superb chapter on the newborn has
been done by Harvard pediatricians Paine and Clifford. A
short section on psychiatric disease in pregnancy was writ-
ten by Mandel Cohen.

Comparing this new volume with the latest edition of the
perennial favorite, W'illiams Obstetrics, one finds that Reid
in somewhat fewer pages has included all the old, familiar
chapters, some in more detail, some in less, and has added
a couple of extras to lure the new reader. Clearly it is too
early to evaluate the place this text will assume in obstetric
teaching in the United States. All of us must try it on the
firing line and find out how it fits our particular demands.
Your reviewer has thoroughly enjoyed those parts of it he
has had time to digest fully and intends to get better ac-
quainted with the rest of it as the academic year progresses.
He urges you to read Reid for yourself.

C. E. McLennan, M.D.

* * *

NATURE OF PSYCHOTHERAPY, THE— A Critique of
the Psychotherapeutic Transaction — Walter Bromberg.
B.S., M.D., Training Consultant, Department of Mental
Hygiene, State of California. Grune & Stratton, Inc., 381
Park Avenue South, New York 16, N. Y., 1962. 108 pages,
$4.50.

This book presents to the reader an interesting and stim-
ulating group of opinions and insights concerning the essen-
tial nature of the psychotherapeutic transaction independent
of its content or the specific theoretical orientation of the
therapist. Although somewhat verbose and circuitous at
times, it presents new dimensions for thinking about the
psychotherapeutic process. This book reflects what appears
to be the major current trend among psychotherapists: the
focus on the interaction and the interactional situation
rather than on what is being spoken about.

Using a combination of elements of theoretical sociologi-
cal analysis, symbolic logic, and epistomology, the author
examines in turn: (1) The basic presuppositions underlying
dynamic psychotherapy; (2) The psychological need to ex-
plain as exists in the psychotherapist; (3) The validity of
the presuppositions which underlie the psychological postu-
lates involved in psychotherapeutic theory; (4) What the
author calls extra-technical elements, the “art of psycho-
therapy”; (5) The therapist’s position of wishing to help
as a commonality in all therapies and a consistency in the
therapist’s position in a therapeutic situation; (6) The lack
of sufficient knowledge of patient-premises underlying his
part of the therapeutic interactions; and, (7) The use of
the, what the author calls, “as if” model that the patient
uses to view the therapist’s intervention. The patient re-
gards the therapist’s explanations as if they were true and,
apparently, is capable of benefiting from this micromodel
of his problems independently of whatever theoretical frame-
work within which this explanation falls. This attempt to
strip the therapeutic process of its content and theoretical
orientation of the therapist, although certainly not new
(Wilhelm Reich and Otto Rank, among others, were strug-
gling with the interactional problem in the early 1920’s)
nevertheless helps the reader focus on an aspect of therapy
which, perhaps, too often is not seen.

One might, however, legitimately ask whether a thera-
peutic interaction can be examined by any of its members.
Parsons has pointed out the importance of perspective in

viewing an interactional system. It is obvious that no one
member of the therapeutic dyad is less determined by in-
teractional influences than the other one. In a sense, there-
fore, the author may not be in a position to be a competent
observer of a therapeutic interaction. The necessity for
what Parsons calls “the significant third person” is demon-
strated in this book in that, perhaps, its most valid obser-
vations concerned the premises of the therapist. The author
admits that he has had little contact with the patient’s part
of the situation. The author’s use of impersonal “tools” such
as the logical examination of the material, was undoubtedly
an attempt to get to this third person, more objective, van-
tage point. One wonders, however, whether his real insights
came to him as a therapist as a member of the dyad and
were then rationalized using whatever logical or sociological
theory analysis tools that seemed to fit.

Although far from a definitive work in the very exciting
area of the exploration of the psychotherapeutic process,
the book brings to the reader some interesting new thoughts
and comments concerning its essential nature. It is hoped
that the author, or some of his coworkers, will use some of
the ideas suggested by this book as impeti for exploring
the psychotherapeutic process in a more observational and
objective way. If this book does nothing but stimulate some
methodological pursuit of these kinds of problems, it will
certainly serve a valuable purpose.

Arnold J. Mandell, M.D.
* * *

STRABISMUS — Symposium of the New Orleans Academy
of Ophthalmology— Raynold N. Berke, M.D., Diplomate,
American Board of Ophthalmology: Assistant Clinical
Professor of Ophthalmology, Columbia University, New
York, N. Y. ; Harold Whaley Brown, M.D., Diplomate,
American Board of Ophthalmology; Clinical Professor of
Ophthalmology, New York University Post-Graduate Med-
ical School, New York, N. Y. David G. Cogan, M.D.,
Diplomate, American Board of Ophthalmology; Professor
of Ophthalmology, Harvard Medical School, Boston, Mass.;
John Woodworth Henderson, M.D., Ph.D., Diplomate,
American Board of Ophthalmology: Professor of Ophthal-
mology, The University of Michigan Medical School, Ann
Arbor, Mich.; Arthur Jampolsky, M.D., Diplomate, Ameri-
can Board of Ophthalmology; Director, Eye Research
Institute, Presbyterian Medical Center, San Francisco,
Calif.; and Marshall M. Parks, M.D., Diplomate, American
Board of Ophthalmology; Attending Ophthalmologist,
Children’s Hospital, Washington, D. C. Edited by George
M. Haik, M.D., Diplomate, American Board of Ophthal-
mology; Professor of Ophthalmology and Head of the
Department, Louisiana State University School of Medi-
cine, New Orleans, La. The C. V. Mosby Company, 3207
Washington Blvd., St. Louis 3, Mo., 1962. 369 pages,
illustrated, $18.00.

This book on strabismus contains the material presented
at a meeting of the New Orleans Academy of Ophthalmol-
ogy. The participants were Doctors Raynold N. Berke, Har-
old W. Brown, David G. Cogan, John Woodworth Henderson,
Arthur Jampolsky, and Marshall M. Parks. The material
was edited by George M. Haik. The book is divided into
14 chapters covering the various phases of strabismus, in-
cluding chapters on the neuroanatomy of ocular motility
and strabismus, the neurology of amblyopia and nystagmus.

The guest speakers are all authorities in their particular
fields of strabismus. In place of the usual considerations on
a purely anatomic basis, the book includes the most modem
concept of the neuroanatomy, physiology and neurology of
the extraocular muscles. It is with this concept in mind that
the esotropias, exotropias and hyeropias are discussed.

Special consideration is given to the “A” and “V” syn-
dromes that have recently received so much attention. Pleop-
tics is also discussed, but one regrets that it isn’t a clear,
concise presentation of this new concept for the treatment
of amblyopia.

VOL. 97, NO. 6

DECEMBER 1962

389

That surgery of strabismus is not an exact science is
brought out by Berke in his presentation. He states that
“Squint surgery must be based largely on empiricism and
trial and error until we know more about the pathologic
changes of nonaccommodative, nonparalytic strabismus.”

The last 59 pages are devoted to a round table discussion
by the panel based on questions from the audience. This is
one of the most important parts of the book and brings out
the fact that there is still considerable difference of opinion
among the authorities.

The book cannot be recommended as a textbook for the
beginner in ophthalmology because of the conflicting and
contradictory opinions expressed. These would only serve
to confuse the student of this somewhat bewildering sub-
ject. The more experienced ophthalmologist can resolve
many of these differences of opinion.

The format is outstanding with good typography and ex-
cellent paper and binding. Except for a few reproductions
of photographs, the illustrations, including line drawings,
surgical illustrations and reproduction of photographs, are
all excellent. The 14-page index is adequate.

Frederick C. Cordes, M.D.
* * *

PRACTICAL ANESTHESIOLOGY— Joseph F. Artusio,
Jr., M.D., Professor of Anesthesiology in Surgery and
Professor of Anesthesiology in Obstetrics and Gynecology,
Cornell University Medical College, New York, N. Y. ;
Anesthesiologist-in-Chief, the New York Hospital-Cornell
Medical Center, New York, N. Y. ; and Valentino D. B.
Mazzia, M.D., Professor and Chairman of the Department
of Anesthesia, New York University School of Medicine
and Postgraduate Medical School, New York, N. Y. The
C. V. Mosby Company, St. Louis, Mo., 1962. 318 pages,
$7.75.

The authors have prefaced the text with a statement of
purpose. The book is designed for medical students and
general practitioners as a handbook of current practices
in anesthesiology and to be of value to the nurse anes-
thetist.

The reviewer has tried to assess the degree of success
which has been achieved by the authors toward reaching
this goal.

The experienced anesthetist at first will be inclined to
regret the author’s failure to consider many of the features
which he believes should be included in any volume whose
title includes the word “practical.” In many instances he
will feel relieved to find many, of what appeared to be,
missing features somewhat hidden in subsequent chapters.

The forty-two chapters containing 300 pages are neatly
divided into five parts — for the most part termed “Consid-
erations.” They include Basic, Preanesthesia, Anesthesia,
Techniques of Administration and Special Considerations.

The chapters on Anatomical and Physiological Considera-
tions, which precede any mention of Anesthetics provide
the medical student with the same dynamic introduction to
anesthesia which is familiar to him in modem, clinically
oriented, medical basic science training. An opportunity to
extend this concept earlier in the text to emphasize the need
for and the means of insuring adequate ventilation in all
patients regardless of the effects of the anesthetic agent,
muscle relaxant or disease process has been missed. For
example an early brief, but clear, explanation of what the
anesthetist aims to accomplish by hand, or respirator, as-
sistance or control of the patient's breathing might provide
better continuity than waiting for a clue eleven chapters
later in a discussion of “Ventilation,” and another hundred
pages for a consideration of “Emphysema.” Many experi-
enced anesthetists will regret that the advantage of slow
flow rates for inflating the lungs with anesthetic atmos-
pheres is not included in the advice regarding inflating
pressures in “Practical Anesthesiology.”

Complete bronchospasm developing during anesthesia
requires early recognition and prompt treatment if a fatal
outcome is to be avoided. Admittedly rare, it probably car-
ries a higher priority of practicality than the danger of
skin necrosis from the weight of the breathing tubes.

Many clinical anesthetists will take exception to the
sole reference to ethyl chloride i.e. “explosive, may produce
cardiac arrest during induction, it is not recommended.” A
similar disastrous result from ethyl ether vaporized in a
copper kettle is entirely possible if improperly administered.

The list of “Suggested Readings” following each chapter
reveals an excellent selection for which the authors are to be
congratulated.

Practical Anesthesiology appears to be an extension of
the lectures given by the authors to their students. In all
likelihood it will be adopted as a text by other medical
schools. Students and others using the book will be well
advised to make constant reference to the “Suggested
Readings.”

The resident in anesthetics will do well to read the book
and check his everyday performance against the Do’s and
Don’ts in Chapter 32.

All persons administering anesthetics will benefit from
reading this book.

William B. Neff, M.D.

^ ^

MODERN MEDICAL TREATMENT— by various au-
thors. Edited by Henry Miller, M.D., F.R.C.P., Physician
in Neurology, Royal Victoria Infirmary, Newcastle upon
Tyne. Williams & Wilkins Co., Baltimore 2, Maryland,
exclusive U. S. agents, 1962. 416 pages, $7.00.

As the author indicates in the preface, the primary pur-
pose of this book is to acquaint the busy physician with
therapeutic procedures which are acceptable and practicable
in the treatment of patients who are afflicted with any of the
more common diseases. As an approach to therapy, there
are given brief descriptions of the respective disease proc-
esses and helpful diagnostic information. In most instances,
anticipated responses and results are described and evalu-
ated. Contraindications for the use of medicaments and
other therapeutic procedures are included. An appendix of
diets is a practical addition.

Although the author states that “the book makes no
claims to be comprehensive,” and that “its scope is limited
to diseases encountered in the United Kingdom,” it is ex-
ceptionally well done and is readily applicable to conditions
in the United States. Unquestionably this compact and in-
formative book will receive practical daily use by any prac-
ticing physician who has one.

* * *

PROPERTIES OF MEMBRANES AND DISEASES OF
THE NERVOUS SYSTEM — Based on the Symposium,
June 1961, Sponsored Jointly by the American Neurological
Association and the American Association of Neuropathol-
ogists, Inc. ; Donald B. Tower, Sarah A. Luse, Harry
Grundfest. With discussions by Abel Dajtha, Murray B.
Bornstein, and Ichyi Tasaki. Foreword by Melvin D. Yahr.
Springer Publishing Company, Inc., 44 East 23rd Street,
New York 10, N. Y., 1962. 102 pages, $4.50.

This monograph brings together current thinking of the
neurochemists, electron microscopists, and neurophysiolo-
gists, demonstrating how potentialities of the intra and
surface cellular membranes of neurons may act as selective
barriers producing separate functional units which are vital
mechanisms of conduction, transmission, and reception of
nerve impulses.

The publication advances our clarification of the exchange
of ions, not only between membranes but within the mem-
brane itself. There are not only compartmented metabolic
functions separated by the membranes of opposing neurons
but also compartmented metabolic functions within the

390

CALIFORNIA MEDICINE

neurons themselves. The blood-brain barrier has now been
further clarified by demonstrating the highly specialized
function of transport, and exclusion of molecules, including
ions, but the special structure and function of cellular
membranes of the special cellular elements of the nervous
system, particularly the neuron and the astrocytes. The vari-
able degree of permeability and impermeability of cell
membranes in relation to pinocytosis and phagocytosis, as
well as the manner in which certain viruses can adapt
themselves to the invasion of the special membranes of
neuronal elements, has been an important neurobiological
advance in our understanding of the pathogenesis of the
so-called “neurotropic” viruses, particularly in relation to
release of viral DNA into host cells. The electronmicro-
scopic study of myelin has clarified its formation from the
cell membrane and cytoplasm of Schwann cells of peripheral
nerves and oligodendrocytes of the CNS.

Though this monograph on the properties of membranes
of the nervous system seems remote from the diagnosis and
treatment of neurological disorders, such investigations are
laying the groundwork for further clarification of the
etiology and pathogenesis of disorders of the nervous system,
a specialty in medicine where ignorance continues to out-
weigh knowledge.

Knox Finley, M.D.

* * *

ILLUSTRATED MANUAL OF NEUROLOGIC DIAG-
NOSIS— R. Douglas Collins, M.D., Captain, XJSAF, MC,
Neurologist, 7505th USAF Hospital R.A.F. Burderop,
Wiltshire, England; former special trainee for the Na-
tional Institute of Neurological Diseases and Blindness,
Jefferson Medical College Hospital, Philadelphia. With a
Foreword by Rudolph Jaeger, M.D., Professor and Chief,
Department of Neurological Surgery, Jefferson Medical
College and Hospital, Philadelphia. J. B. Lippincott Com-
pany, East Washington Square, Philadelphia 5, Pa., 19G2.
177 pages, 97 illustrations of Neurologic Diseases, .$12.00.

Dr. Collins’ goal was to present a simplified technique
for the average physician to suspect neurologic disease.
Within the limits of the complexity of the subject, the
author is well on his way to accomplishing his aim in a
brief, readable if somewhat oversimplified format. The es-
sential neuroanatomy around which neurologic localization
is built is portrayed in semi-diagrammatic colored plates
conveniently coded. The basic principle of establishing the
location of the lesion and then its nature is followed in the
organization.

A visual recapitulation of the steps in the neurological
examination is offered initially and the author has given
at least one established approach to the elicitation and
interpretation of each important neurologic sign. There
follows a simple tabulation of abnormal findings which
would be associated with disease in the various anatomical
sites of the neuraxis, first in the longitudinal and then in
the transverse dimension. In this category little attention
is given to cervical spine or cervical vessel findings or the
abnormalities of pediatric neurology or the deformations
observed in the spine and extremities or about the orbits.

In the tabulation it is difficult to give emphasis to the
relative importance of the various signs which are elicited.
A tabulation of the possible pathologic changes to be found
in association with disease in specific anatomical sites or
systems is presented. A list of the various laboratory diag-
nostic procedures and their indications is useful. A central
100 pages of the book are devoted to a presentation of ex-
amples of disease entities involving one or more portions of
the neuraxis.

A most elementary protocol of a case and the differential
diagnosis is presented together with the visual display of
the location of the disease. No inclusion of pathologic de-
tails or therapy is attempted. Details are not to be found in
this book. No processes are described comprehensively.

The author provides a brief list of general neurologic
reference texts to which the physician may refer. A sum-
mary of the parts of the body which require examination
and the features to look for in the examination of that par-
ticular part is appended as is a breakdown of the signs
which may be interpreted as involving one or multiple
tracts or specific systems above and below the foramen
magnum.

A brief glossary to terms which might be unfamiliar is
included and a reasonable index completes the volume. The
general approach is one of making easy, in almost cookbook
fashion, the elicitation and interpretation of abnormal find-
ings without any attempt to discuss disease as such. Little
or no emphasis is placed upon the history or the tempo of
the disease. In the glossary the reader will not find a care-
ful breakdown of the important terms applied to impair-
ment of consciousness and one finds the term “semi-con-
scious” appear within the book.

One might argue with utilization of the term “platy-
basia” as opposed to “basilar invagination” or “basilar
impression” as being responsible for one of the neurologic
syndromes which is presented. These critical points merely
appear as a result of the laudable attempt to put into a
short book and in the most elementary form the essentials
of the field such that the average physician may have a
workable skeleton upon which to build his assessment of
his patient’s problem. The diagrams are well presented, if
not detailed. The print is most readable. The book is beau-
tifully produced. The cost is explained in part by the nu-
merous color plates. This is a book for the student of
elementary neurology, nothing more.

W. Eugene Stern, M.D.

* * *

FUNDAMENTAL SKILLS IN SU RG ERY— Thomas F.
Nealon, Jr., M.D., Associate Professor of Surgery, Jeffer-
son Medical College. Illustrated by Ellen Cole. W. B.
Saunders Company, West Washington Square, Philadel-
phia 5, Pa., 1962. 289 pages, $8.50.

The conscientious interne or junior resident who has just
received a surgical service assignment, faces his new
position with a certain amount of fear, apprehension and
confusion. This book is written with this chap in mind;
to guide him in fundamentals which he later will do auto-
matically. It is strictly a Primer for the embryo surgeon,
which is the author’s intent, and which makes it an entirely
different text book. The twenty-two chapters are well
illustrated and concise giving information regards routine
surgical care, surgical instruments, operating room conduct,
sutures, dressings and anesthesia, infection, burns, minor
surgery of superficial tissues and gastrointestinal intubation.
Problems which the embryo surgeon may encounter and
which he may have to be prepared to deal with “on his
own” are reviewed in separate chapters on head and neck,
upper extremity, breast, chest, abdomen, anorectal region,
lower extremity and urinary tract, with one on infants and
children. A separate chapter on resuscitation and one on the
circulatory system including fluid and electrolyte therapy
completes the review.

The seasoned surgical resident will of course consider
this book as too elementary, but the fledgling who has not
yet attained such exalted position, will welcome the helping
hand which this book affords. The author covers about
everything which the embryo surgeon might encounter in
his surgical service. I would make one suggestion or criti-
cism and that is that the chapter on electrolytes should
have been more inclusive of the various problems which
may and do so often arise to confuse the whole staff.

Conrad J. Baumgartner, M.D.

VOL. 97, NO. 6 • DECEMBER 1962

391

TEXTBOOK OF OPHTHALMOLOGY— Seventh Edition

— Francis Heed Adler, M.D., Emeritus Professor of Oph-
thalmology, University of Pennsylvania Medical School;
Consulting- Surgeon, Wills Eye, Philadelphia General, and
Children’s Hospitals of Philadelphia. W. B. Saunders
Company, Philadelphia, Pa., 1962. 560 pages, Illustrated
with 288 figures and 26 color plates, $9.00.

This is the 7th edition of the book originally written by
Sanford Gifford, first published in 1938. It was written pri-
marily as a textbook on ophthalmology for the medical stu-
dent and general practitioner. The book eliminated all the
rare conditions and dealt witli the “run-of-the-mill” condi-
tions that would be of interest to the medical student and
to the general practitioner.

Upon Gifford’s death, Adler took over the revision of the
book and has improved it with each new edition. As stated
in the preface, Adler has consistently given space only to
those features of ophthalmology that are of medical and
neurological interest.

The book is divided into 24 chapters. The first few chap-
ters deal with the various methods of examining the eye
and its functions. This is followed by chapters on the dis-
eases of the various structures of the eye. The chapters near
the end of the book discuss the ocular disorders due to dis-
eases of the central nervous system; the ocular manifesta-
tion of general diseases and the therapeutic agents used in
ophthalmology.

The final chapter, which is on ocular injuries, is a very
convenient, concise account of the first aid treatment of eye
injuries.

The most unusual new feature of the book is the first
chapter on symptomatology of eye diseases. This is divided
into two parts, the first discussing the ocular visual symp-
toms, the second part dealing with non-visual symptoms.
After each symptom, in parentheses, is a reference to some
portion of the book. For example, under sudden loss of
vision of one eye are listed a number of causes. One of
these is central retinal vein obstruction, and at the end of
this statement is a page reference to a section of the book
dealing with this subject.

The book has become a classic for the medical student
and the general practitioner. It is also recommended as a
good introduction to the subject of ophthalmology for the
first-year resident in ophthalmology. To the practicing oph-
thalmologist, it is a handy, condensed, concise reference
book.

The index is adequate. The format is excellent, the paper
is of good quality and the print easily readable. The line
drawings, reproduced photographs and color reproductions
are outstanding. The binding is good and should withstand
a good deal of use.

All in all, it is an excellent book.

Frederick C. Cordes, M.D.
* * *

THE MOLD OF MURDER — A Psychiatric Study of
Homicide — Walter Bromberg, M.D., formerly Director,
Psychiatric Clinic, Court of General Sessions, New York,
N. Y., and Training Consultant, Department of Mental
Hygiene, State of California. Grune & Stratton, Inc., 381
Park Avenue South, New York 16, N. Y., 1961. 230 pages,
$4.75.

Television’s fare, current paper-backs, and the continuing
popularity of Edgar Allen Poe attest to man’s perennial in-
terest in and fascination with violent crime. In this new
book Dr. Bromberg narrows the field of his earlier Crime
and the Mind, published in 1948, to present an exploration
of murder, focusing primarily on the murderer and the
society in which he develops. Turning his attention first to
the “normal” murderer, the author then discusses among
others, the female murderer, the psychopathic murderer, the
psychotic killer, the adolescent murderer, the emotionally

immature, the role of alcohol, the sexual psychopath. Some
medico-legal problems are explored. Throughout, the author
emphasizes the dynamic, motivated significance of the mur-
der act to the individual murderer. Murder occurs when
“the inhibiting, defensive or sublimating mechanisms of the
ego are insufficient to curb direct expression of aggressive
impulses.” A second main theme of this book is the intimate
role of society in the murder phenomenon. The author
pointedly reduces the gap between the average man and the
murderer. “The criminal acts out those impulses and fan-
tasies which the law-abiding citizen represses and abhors
. . . society loves its crime but hates its criminals.” There
is even a possible analogy here, which the author does not
draw, between Szurek and Johnson’s adolescent delinquents
who are acting out the unconscious wishes of the parents,
and the murderer’s relation to society. In his discussion on
prevention of murder, the author presents an unusual pro-
posal that television be used in a long-term “psychodrama
by television” mass educational program. The author has
made liberal use of case histories which are interestingly
presented. This is not a textbook, but an absorbing, read-
able, often penetrating exploration of an important prob-
lem. The author’s presentation tends to develop in his reader
a certain attitude and approach to the problem of homicide
which breaks down traditional individual and societal mech-
anisms of isolation and reaction formation. Though quite
suitable for the intelligent layman, the book is of especial
interest to those who are in more direct contact with the
problem of murder: judges, lawyers, probation and parole
offices, social workers, etc. A bibliography and index are
included.

Ronald S. Mintz, M.D.

JjS sJ5 H5

PROGRESS IN RADIATION TH ERAPY— Volume II—

Edited by Franz Buschke, M.D., Professor of Radiology,
University of California School of Medicine, San Fran-
cisco (With 17 contributors). Grune & Stratton, Inc., 381
Park Avenue South, New York 16, N. Y., 1962. 266 pages,
$12.50.

Like its predecessor, this small monograph consists of a
series of articles dealing with the various phases of clinical
radiotherapy and allied topics.

The first two chapters deal with so-called radiation ne-
phritis. The value of these would be enhanced were an
attempt made to correlate more clearly the presumed radia-
tion changes with the precise estimated kidney dose (ex-
pressed in roentgens, time and area) . The author, Luxton,
does emphasize “in the diagnosis of radiation nephritis, it
is important to know the state of the kidneys before radio-
therapy.” Since this information is often lacking, many of
the statements are post hoc in nature.

There is an excellent chapter on tolerance of cartilage
and bone in clinical radiation therapy by R. G. Parker.
This clinical therapist notes that in a study of 110 epithelio-
mata of the skin of the nose, in which two-thirds of the
cases had involvement over the tip of the nose or the ala,
and who were treated over ten years ago with conventional
low voltage x-ray therapy (120 kv), or orthovoltage (200 kv)
to doses up to 4600 r skin, in 5 days, there had only been a
single instance of cartilage necrosis. This involved the an-
terior nasal septum, was then associated with persistent
tumor and has subsequently been cured by resection. This
reviewer agrees that with competent orthovoltage radiother-
apy the incidence of cartilage insult in the treatment of
most skin cancers is nominal. In this same section, the
author points out that “supervoltage” irradiation has not
been established as reducing the incidence of bone necrosis.

There is a chapter on periodic fractionation of treatment
by Botstein which might be described as more enthusiastic

392

CALIFORNIA MEDICINE

than informative. Together with a few of the other chapters
in this monograph, this one particularly shows the need for
adequate controls before making sweeping conclusions as to
apparent improvements. Indeed, one hopes all the contribu-
tors will read Dr. Buschke’s thoughtful comments on page
4 dealing with the evolution of 606, and the fact that its
discoverer did not publish the 605 unsuccessful attempts
leading to the development of that valuable therapeutic
agent.

The recrudescence of interest in attempting conjunction
of radiation and surgery is discussed by Bloedorn who em-
phasizes on page 127 that “these studies are still incomplete
and give only fragmentary information.” Again, the need
for controls is manifest. This reviewer questions the wisdom
of the sentence “radiotherapists should be more aggressive
in the treatment of advanced cancers which are still local-
ized . . . bladder . . .” Aggressiveness in the face of non-
radiocurable disease may leave the unfortunate patient con-
siderably less happy than before. On the other hand this
same author must be commended for his observation :

“A common mistake in radiotherapy is to consider that
the irradiation ought to be started as soon as the diagnosis
of malignancy is made ... an attitude (often) imposed by
the referring physician ... in the particular group of pa-
tients dealt with in this kind of combined therapy, the
malignancy is probably older than a year, and a waiting
period of two to three weeks, especially if used to improve
the general and local condition, will make little difference
in the local extension of the tumor or in the production of
metastases.”

The chapter on chemotherapy by Papac brings up to date
the present attitude towards the use of this agency alone or
in conjunction with radiation therapy. Concerning 5-fluorou-
racil, she observes that the responses with this drug have
generally been brief, few exceeding even three months in
duration. The response rate in cancer of the breast is re-
ported as varying upwards from 10 per cent, and in cancer
of the colon from 10 to 15 per cent. The drug has a narrow
therapeutic range and in effective doses, regularly produces
clinically significant and often serious toxicity. In fact, in
the treatment of carcinomas of the gastrointestinal tract,
the use of this drug is best considered an investigative
rather than a conventional therapeutic modality.

There is a chapter on reirradiation by Kramer which is
useful, and one on limitations of histologic diagnosis by
Rambo which should be required reading for physicians
dealing with carcinoma.

In a brief, 13-page introduction, the editor makes a plea
for division of radiological residency training into separate
therapeutic and diagnostic pigeonholes, although he be-
lieves that “general radiologists are still needed.” He
produces no scientific evidence to support the belief that
localized, curable cancer is better handled by a radiation
therapist than by a general radiologist. On the contrary he
stresses the importance of sound clinical judgment and in-
dividualization of therapy, which certainly is attainable by
a good clinician in either of these disciplines. He notes
that in Russia a broad plan calls for the training of 2,000
radiotherapists between 1960 and 1965, but one of his chap-
ters (contributed by Lenz after a month in Russia three
years ago) contains the not unexpected news that “among
1,348 physicians working in oncology in the Russian Fed-
erated Republics, only 30.7 per cent had what would be
considered adequate training,” a shortcoming adumbrated
by Koslova.

Perhaps the only criticism of this interesting monograph
should be applied to the second paragraph on page 2 in
which well established orthovoltage roentgen therapy is
accorded a rather cavalier, carbolic acid spray. The author

seems to forget that Meschan and colleagues after 8 years’
experience with telecobalt beam therapy recently reported
an increasing incidence of serious late complications — late
subcutaneous and deeper fibrotic changes which are prov-
ing to be disabling to patients. In addition to impairment of
function of the affected part, there are instances of serious
neurologic damage, osteoradionecrosis, ulceration and steno-
sis of intestine, fractures of femoral neck, and pelvic fibrosis
simulating persistent or recurrent neoplasm. These compli-
cations, in competent hands, are fortunately not common.
However, they have replaced the skin insults of earlier radio-
therapy which were indeed more readily recognized and
more easily treated. This reviewer is sure that subsequent
volumes will deal with these problems in adequate detail
and will stress that small cobalt and cesium units are in
fact less effective both physically and clinically than stand-
ard 250 kv orthovoltage x-ray therapy apparatus. It is the
voltage of the radiologist’s brain and not his machine that
is important.

L. H. Garland, M.D.

* * *

ESSENTIALS OF PEDIATRIC PSYCH I ATRY— Rubin
Meyer, M.D., Associate Professor of Pediatrics, Morton
Levitt, Ph.D., Professor of Psychology and Assistant
Dean; Mordecai L. Falick, M.D., Associate Professor of
Psychiatry; and Ben O. Rubenstein, Ph.D., Associate Pro-
fessor of Psychiatry, Wayne State University College of
Medicine, Appleton-Century-Crofts, Meredith Publishing
Company, 34 West 33rd Street, New York 1, N. Y., 1962.
208 pages, $6.00.

The appearance of this book marks one more bridge be-
tween the pediatric practitioners seeking for help with psy-
chologic problems and those clinicians whose time is spent
mostly dealing with such difficulties. The organization of
this book is most intriguing. The authors have taken a very
reasonable number of pages to discuss the relation between
pediatrics and psychiatry both historically and currently.
Secondly, the foreword of this book contains a very clear
and yet brief description of psychic development so that the
pediatrician or general practitioner reader may understand
the complex problems of this maturation. There is a clear
treatment of the conscious and unconscious and of the var-
ious defense mechanisms that all of us use in order to avoid
both our anxieties and those problems which grow out of our
anxiety.

It is this comprehensive presentation of modern theory
that makes the description of specific clinical situations
much more understandable. It becomes possible for the
reader to understand how the particular problems of child-
hood grow out of the abnormalities of psychic development.
The authors then go on to discuss both normal and abnormal
development and then take up special problems which re-
sult as disorders of such development. Special chapters are
given to the emotional reactions of trauma and hospitaliza-
tion, to the brain damaged and mentally defective child,
and to certain of the special clinical syndromes such as the
psychoses.

Finally a clear discussion of diagnostic measures is in-
cluded. This is important not only in itself but as pointing
the way to an adequate and suitable kind of referral. It is
the clarity with which this is done that makes this book, in
addition to its good consistent theoretical base, a very valu-
able one. Many of the textbooks written for pediatricians
tend to approach the child in a very piecemeal fashion and
discuss different psychiatric disorders as if they were re-
mote entities. This book has succeeded in avoiding this
problem, and very properly belongs in the office of the pedi-
atrician or general practitioner dealing with children and
their parents.

Henry H. Work, M.D.

VOL. 97, NO. 6 • DECEMBER 1962

393

AUTHOR INDEX

Anderson, Gail V., Los Angeles 158

Anderson, John, Monterey 174

Ashley, Franklin, Los Angeles 8

Baldwin, John N., San Francisco 359

Bennett, A. E., Berkeley 346

Bierman, Howard R., Beverly Hills 301

Blazina, Martin E., Los Angeles 61

Bonney, William, Los Angeles 8

Briggs, John N., Encino 233

Brown, Adolph M., Beverly Hills 291

Brown, Barton A., San Francisco 268

Brown, Marthe E., Beverly Hills 291

Bruce, Peter, Melbourne, Australia 8

Cain, Harvey D., Vallejo 31

Caldwell, Alexander B., Jr., Los Angeles 281

Carpenter, Charles, Cos Angeles 333

Carter, Frank H., San Diego 177

Daily, Edwin F., New York 58

Demaree, Eugene W., Pasadena 220

Dong, Eugene, Jr., Palo Alto 148

Dorsey, Clete, Pasadena 176

Drake, Elvin C., Los Angeles 61

Dubuy, Carl, Monterey 174

Duckler, Lawrence, Portland, Oregon 35

Estridge, M. N., San Bernardino 71

Falco, Frank G., Pacific Palisades 31

Feeney, M. J., San Diego 235

Fender. Frederick A., San Francisco 227

Franco, Jorge, San Jose 352

Frazier, Donald B., San Diego. 177

Freidell, H. Vernon, Santa Barbara 80

Friend, William K., Santa Ana 56

Gaffey, William R., Berkeley (LE) 316

Garland, L. Henry, San Francisco (LE) 124

Gebhart, William F., Santa Barbara 80

Gerbode, Frank, San Francisco 51

Glassock, Richard, Los Angeles 8

Golden, Joshua S., Los Angeles 281

Goldman, Ralph, Los Angeles 8

Goodman, Joseph R., San Francisco 278

Goodwin, Willard E., Los Angeles 8

KEY TO ABBREVIATIONS USED

(Or.) — Original Article; (Ed.) — Editorial; (CMA) — California
Medical Association: (CR) — Case Report; (I) — Information; (LE) —
Letters to the Editor; (PE) — Page End.

Hagstrom, Jack W. C., New York 359

Hamel, Neal C., Encino 233

Harris, M. Coleman, San Francisco 286

Hattori, Mitsuo, Los Angeles 16

Haywood, L. Julian, Los Angeles 206

Heiskell, Charles L., Newport Beach 333

Hill, Edward C., San Francisco 216

Holeman, Charles W., Bakersfield 333

Hollander, F. G., San Diego 235

Howe, G. E., San Diego. 235

Hurley, Edward J., Palo Alto 148

Iwai, Seizo, Los Angeles 16

Jacobs, Lewis G., Palo Alto 163, 316

Jorgensen, Melford B., Los Gatos 364

Johnston, D. Gordon, Oxnard 12

Johnstone, Marshall W., Pasadena 222

Kahn, Arthur, Kansas City, Kansas 341

Katz, Louis Nv Chicago, Illinois 201

Kaufman. Joseph J., Los Angeles 8,355

Kellogg, Frederick, Long Beach 278

King, Ruth M., Los Angeles 158

Landes, Bernard A., Long Beach 77

Leigh, M. Digby, Los Angeles 16

Lennette, Edwin H., Berkeley 1

Lichter, Max L., Melvindale, Michigan 24

Liechti, Robert, Long Beach 278

Lower, Richard R., Palo Alto 148

Magoffin. Robert L., Berkeley 1

May, Ivan A., Oakland 350

Marks, Richard M., Encino 75

Marmor, Judd, Beverly Hills 212

Maronde, Robert F., Los Angeles 206

Martin, Howard F., Palo Alto 293

Mastroianni, Ellen, Fort Ord 22

Meherin, J. Minton, San Francisco 209

Michael, Paul, Monterey 174

Miller, Jerry B., Los Angeles 355

Mims, Matt M., Los Angeles 8

Moorman, Henry D., Pasadena 220

Mullenix, R. B., San Diego 235

Neff, William B., Redwood City 28

Oat way, William H. Jr., Altadena 142

O'Neil, Lloyd F., Aurora, Illinois 293

394

CALIFORNIA MEDICINE

Perez, Feliciano M., San Francisco 166

Pevehouse, Byron C., San Francisco 268

Pion, Ronald Joseph, Los Angeles 281

Pomerat, C. M„ Pasadena 273

Porter, Robert W., Long beach 278

Powell, Noble A., Jr., Oxnard 12

Prentiss, R. J., San Diego 235

Ragan, John T., Beverly Hills 338

Redeker, Allan G., Los Angeles 341

Reed, William B„ Burbank 333

Rigby, Elmer C., Los Angeles 363

Rosen, Edward, Oakland (LE) 316

Rossman, Phillip L., Los Angeles 363

Rubin, David, Los Angeles 170

Ryan, Patricia A., Fort Ord 22

Salkin, David, Altadena 142

San Pedro, Jovita M., Los Angeles 16

Sarracino, John B., Fort Ord 22

Schoff, Charles E., Sacramento 298

Schulkins, Thomas A., Encino 233

S U B J E C

A.M.A. Committee on Nursing, Objectives and Program

of the (I) 326

Accreditation of Nursing Homes and Related Facilities,

Charles E. Schoff (Or.) 298

Acholuria, see Viral Hepatitis

Acute Radiation Exposure, Committee on Occupational

Health (CMA) 193

Acute Radiation Nephritis, John N. Baldwin and Jack

W. C. Hagstrom (CR) 359

Adenocarcinoma. Primary, of the Appendix, A Report
of Two Cases, Paul Michael, Clyn Smith, Jr., Carl

Dubuy, and John Anderson (CR) 174

Aged, Medical Assistance to the (Ed.) 237

Ammoniacal Dermatitis — Clinical Observations on an
Efficacious, Economical and Neglected Treatment,

William K. Friend (Or.) 56

Aneurysms, Abdominal Aortic, see Rupture of Abdomi-
nal Aortic Aneurysms, etc.

Angiography, Cerebral, Its Use in Acute Head Injuries
and Undiagnosed Coma, Byron C. Pevehouse and

Barton A. Brown (Or.) 268

Anxiety and Worry as Aspects of Normal Behavior,

Judd Marmor (Or.) 212

Aortic Arch, Double, Clifford F. Storey (Or.) 68

Appendicitis and Pregnancy, Ruth M. King and Gail

V. Anderson (Or.) 158

Appendix, Primary Adenocarcinoma of the, A Report
of Two Cases, Paul Michael, Clyn Smith, Jr., Carl

Dubuy and John Anderson (CR) 174

Arterial Occlusive Disease, Management of Peripheral,

Travis Winsor (Or.) 152

Arthrodesis of a Knee for Neuropathic Disease, Frank

E. Winter (CR) 33

Athletes, Track, Fatigue Fractures in, Martin E. Bla-
zina, Robert S. Watanabe and Elvin C. Drake (Or.).. 61

Back Injuries, Acute. Initial Care of, J. Minton Me-
herin (Or.) 209

Selzer, Arthur, San Francisco 51

Shaffer, Robert N., San Francisco 343

Shumway, Norman E., Palo Alto 148

Simon, Harold J., Palo Alto 135

Smith, Clyn, Jr., Monterey 174

Smith, Roger A., San Bernardino 71

Starr, Paul, Los Angeles 263

Steele, John D., San Fernando 64

Stegeman, Wilson, Santa Rosa 27

Stofer, Raymond C., Palo Alto 148

Storey, Clifford F., San Diego 68

Tashma, Joseph, Beverly Hills 301

Teller, Edward, Berkeley 257

Thompson, Richard C., San Mateo 28

Turner, Roderick D., Los Angeles 8

Wallerstein, Ralph 0., San Francisco 180

Watanabe, Robert S., Los Angeles 61

Winsor, Travis, Los Angeles 152

Winter, Frank E., Visalia 33

Yonemoto, Robert H., Duarte 166

INDEX

Bed Rest, see Compression Neuropathy of the Ulnar
Nerve

Behavior, Normal, see Anxiety and Worry
Bladder, Carcinoma of, see Papillary Carcinoma
Blood, Citrated, see Transfusions

Blood Transfusions, Criteria for. Noble A. Powell Jr.

and D. Gordon Johnston (Or.) 12

Brain Tumor, see Dental Infection

Bricker Procedure, see Papillary Carcinoma of the
Bladder

“Brittle” Features (of) Diabetes Mellitus due to Car-
diospasm, Phillip L. Rossman and Elmer C. Rigby

(CR) 363

Bronchial Division in the Treatment of Pulmonary Tu-
berculosis, John D. Steele (Or.) 64

Bronchiectasis, Post-Tuberculous, Indications for Surgi-
cal Treatment, Neal C. Hamel, John N. Briggs and

Thomas A. Schulkins (Or.) 233

Bronchographic Contrast Mediums, Howard F. Martin

and Lloyd F. O’Neil (Or.) 293

Bureau of Research and Planning:

Hospital Bills — What Proportion Is Paid by Insur-
ance? 45

Inability of the Consumer Price Index to Measure

“Cost of Quality” of Medical Care 128

Type of Practice of Physicians in Non-Federal Prac-
tice in California for Three Periods (from) Mid-

1959 to January, 1962 195

Financing and Provision of Medical Care in Cali-
fornia 249

Use of, and Satisfaction with, C.M.A. Relative Value
Studies by Physicians in Active Practice in Cali-
fornia 323

Characteristics of Physicians in California, Spring,

1961 317

Health Insurance for Senior Citizens 381

C.M.A. Relative Value Studies, see Bureau of Research
and Planning

California Physicians’ Service, L. Henry Garland (LE) 124

VOL. 97, NO. 6 • DECEMBER 1962

395

Cancer, Metastatic Mammary, see 5-Fluorouracil
Cancer Therapy — Evaluation of Supervoltage X-Ray:

Review of the Literature, Lewis G. Jacobs (Or.) 163

Letter to Editor, William R. Gaffey 316

Reply, Lewis G. Jacobs 316

Carcinoma of the Bladder, see Papillary Carcinoma, etc.
Cardiac Failure, Correctable, Arthur Selzer and Frank

Gerbode (Or.) 51

Cardiospasm, “Brittle” Features (of) Diabetes Mellitus
Due to, Phillip L. Rossman and Elmer C. Rigby

(CR) 363

(Care of the Aged — King-Anderson Bill) The Next

Step (Ed.) 84

Care of the Umbilical Cord in the Newborn — A Pro-
gram to Reduce Infection and Promote Healing, John
B. Sarracino, Patricia A. Ryan, and Ellen Mas-

troianni (Or.) .' 22

Cat Scratch Disease — Its Importance in the Differential
Diagnosis of Regional Adenopathic Changes, Melford

B. Jorgensen (CR) 364

Cells, Malignant, Enigma of Circulating, The, Felici-
ano M. Perez and Robert H. Yonemoto (Or.) 166

Cerebral Angiography — Its Use in Acute Head Injuries
and Undiagnosed Coma, Byron C. Pevehouse and

Barton A. Brown (Or.) 268

Characteristics of Physicians in California, Spring 1961,
see Bureau of Research and Planning
Children, Young, Surprises in Operations on the In-
guinal Area of, Richard M. Marks (Or.) 75

Chloramphenicol, Ralph 0. Wallerstein (Ed.) 180

Cholesterol, Serum. Decrease in, with Surgical Stress,
Joseph R. Goodman, Frederick Kellogg, Robert W.

Porter, and Robert Liechti (Or.) 278

Chromosomes of Leukocytes — The Problem of Human

Individuality, C. M. Pomerat (Or.) 273

Civil Defense, A Role for the Physician in, Max L.

Lichter (Or.) 24

Coccidioidomycosis, see Serum Protein Profiles
Coma, Undiagnosed, see Cerebral Angiography
Committee on Occupational Health (C.M.A.) :

10. The Industrial “Blank Check” 122

11. Acute Radiation Exposure 190

12. Parathion Poisoning — A New Antidote 245

13. “Second Aid” . 312

14. Pre-Placement Physical Examinations — Asset or

Liability 377

Communications (Ed.) 303

Compression Neuropathy of the Ulnar Nerve — A Com-
mon Condition Occurring at Bed Rest, M. N. Estridge

and Roger A. Smith (Or.) 71

Congenital Heart Disease — Changing Concepts in the
Surgical Treatment, Norman E. Shumway, Richard
R. Lower, Edward J. Hurley, Eugene Dong Jr., and

Raymond C. Stofer (Or.) 148

Consumer Price Index, Inability to Measure “Cost of
Quality” of Medical Care, Report of Bureau of Re-
search and Planning (I) 128

Correctable Cardiac Failure, Arthur Selzer and Frank

Gerbode (Or.) 51

Criteria for Blood Transfusions, Noble A. Powell Jr.

and D. Gordon Johnston (Or.) 12

Cystectomy, see Papillary Carcinoma of the Bladder

Deans, Newly Appointed (CMA) 182

Decrease in Serum Cholesterol with Surgical Stress,
Joseph R. Goodman, Frederick Kellogg, Robert W.
Porter and Robert Liechti (Or.) 278

Dental Infection Producing Severe Chronic Headache
Simulating Brain Tumor, Howard R. Bierman and

Joseph Tashma (CR) 301

Dermatitis, Ammoniacal, Clinical Observations on an
Efficacious, Economical and Neglected Treatment,

William K. Friend (Or.) 56

Diabetes Mellitus — “Brittle” Features Due to Cardio-
spasm, Phillip L. Rossman and Elmer C. Rigby (CR) 363

Double Aortic Arch, Clifford F. Storey (Or.) 68

Drug Therapy of Hypertension, Robert F. Maronde and

L. Julian Haywood (Or.) 206

Dysphonia, Spastic, Further Study of, Bernard A.

Landes (Or.) 77

Education, Medical, Loans (Ed.) 238

Emphysematous Patients, Pulmonary Operations in,

Ivan A. May (Or.) 350

Enigma of Circulating Malignant Cells, The, Feliciano

M. Perez and Robert H. Yonemoto (Or.) 166

Enterobiasis, Single-Dose Treatment of, (with) Use of

a New Piperazine-Senna Preparation, John T. Ragan

(Or.) 338

Epilepsy, Psychomotor, Psychiatric Aspects of, A. E.
Bennett (Or.) 346

Fatigue Fractures in Track Athletes, Martin E. Blazina,

Robert S. Watanabe and Elvin C. Drake (Or.) 61

Financing and Provision of Medical Care in California,
see Bureau of Research and Planning
Fistula, Vesico-Vaginal, Repair of, Edward C. Hill

(Or.) 216

5-Fluorouracil in Metastatic Mammary Cancer, Eugene

W. Demaree and Henry D. Moorman (Or.) 220

Fractures, see Fatigue Fractures in Track Athletes
Further Study of Spastic Dysphonia, Bernard A. Landes
(Or.) 77

Geriatric Rehabilitation — The Challenge and the Goal,

David Rubin (Or.) 170

Glaucoma, Indications for Operation in, Robert N.
Shaffer (Or.) 343

Hay Fever — A Comparative Clinical Evaluation of
Treatment with Aqueous Pollen Extracts, Alum-Pre-
cipitated Pyridine Pollen Extracts and Aqueous
Pollen in Oil Emulsions, M. Coleman Harris (Or.).... 286

Hazards of Radiation, The, Edward Teller (Or.) 257

Headache, Chronic, see Dental Infection
Head Injuries, Acute, see Cerebral Angiography
Health Insurance for Senior Citizens, see Bureau of
Research and Planning

Health Insurance, What Scope, Edwin F. Daily (Or.).. 58
Heart Disease, Congenital, Changing Concepts in the
Surgical Treatment, Norman E. Shumway, Richard R.
Lower, Edward J. Hurley, Eugene Dong, Jr. and Ray-
mond C. Stofer (Or.) 148

Help for Male Nocturics — A Flexible, Reversible Uri-
nal, Wilson Stegeman (Or.) 27

Hepatitis, Viral, A Study of Hyperbilirubinemia with
Acholuria in Convalescence, Allan G. Redeker and

Arthur Kahn (Or.) 341

Hinshaw, David B., Dean, Loma Linda University

School of Medicine, Newly Appointed (CMA) 183

Homotransplantation of the Kidney, A Successful Case
of, Between Identical Twins, Human Renal Trans-
plantation, Willard E. Goodwin, Matt M. Mims,

396

CALIFORNIA MEDICINE

Joseph J. Kaufman, Roderick D. Turner, Ralph Gold-
man, William Bonney, Franklin Ashley, Richard

Glassock and Peter Bruce (Or.) 8

Hospital Bills — What Proportion Is Paid By Insurance?
Bureau of Research and Planning (I) 45

Human Renal Transplantation, II — see Homotrans-
plantation of the Kidney
Hyperbilirubinemia, see Viral Hepatitis

Hypernephroma — Disappearance of Metastasis After
Nephrectomy, R. J. Prentiss, F. G. Hollander, R. B.

Mullenix, M. J. Feeney and G. E. Howe (CR) 235

Hypertension, Drug Therapy of, Robert F. Maronde and

L. Julian Haywood (Or.) 206

Hypertension, Newer Concepts in Relation to, Louis N.

Katz (Or.) 201

Hypothyroidism, Subclinical, Recognition and Treat-
ment, Paul Starr (Or.) 263

Inability of the Consumer Price Index to Measure “Cost
of Quality” of Medical Care, see Bureau of Research
and Planning

Indications for Operation in Glaucoma, Robert N.

Shaffer (Or.) 343

Industrial Accident Commission Minimum Fee Sched-
ule, Edgar Rosen (LE) 316

Industrial “Blank Check,” Committee on Occupational

Health (CMA) 122

Infection. Dental, Producing Severe Chronic Headache
Simulating Brain Tumor, Howard R. Bierman and

Joseph Tashma (CR) 301

“Ingrown” Nails and Other Toenail Problems — Surgi-
cal Treatment, Marshall W. Johnstone (Or.) 222

Inguinal Area, Surprises in Operations on the, of Young

Children, Richard M. Marks (Or.) 75

Initial Care of Acute Back Injuries, J. Minton Meherin

(Or.) 209

Insurance, Health, What Scope, Edwin F. Daily (Or.).... 58

Insurance, What Proportion (of) Hospital Bills Is Paid
By, Bureau of Research and Planning (I) 45

Keogh Bill, The (Retirement Plan — Tax Deductibility)

(Ed.) 366

Kidney, Artificial, in Snakebite, Use of the, Donald B.

Frazier and Frank H. Carter (CR) 177

Kidney, see Homotransplantation of the
(King-Anderson Bill, Care of the Aged) The Next

Step (Ed.) 84

Knee. Arthrodesis of a, for Neuropathic Disease, Frank
E. Winter (CR) 33

Leukocytes, Chromosomes of, The Problem of Human

Individuality, C. M. Pomerat (Or.) 273

Loans, Medical Education (Ed.) 238

Malignant Cells, Enigma of Circulating, The, Feliciano

M. Perez and Robert H. Yonemoto (Or.) 166

Mammary Cancer, see 5-Fluorouracil

Management of Peripheral Arterial Occlusive Disease,

Travis Winsor (Or.) 152

Mechanical Aids at the Operating Table, Richard C.

Thompson and William B. Neff (Or.) 28

Medical Assistance to the Aged (Ed.) 237

Medical Care in California, Financing and Provision of,
see Bureau of Research and Planning
Medical Care, Inability of Consumer Price Index to
Measure “Cost of Quality” of, Report of Bureau of
Research and Planning (I) 128

Medical Education Loans (Ed.) 238

Mellinkoff, Sherman M., Dean, UCLA School of Medi-
cine, Newly Appointed (CMA) 183

Minimum Medical Fee Schedule, Industrial Accident

Commission, Edgar Rosen (LE) 316

Myeloproliferative Disorders, The — Current Clinical
and Laboratory Considerations, Jorge A. Franco
(Or.) 352

Nephrectomy, see Hypernephroma

Nephritis, Acute Radiation, John N. Baldwin and Jack

W. C. Hagstrom (CR) 359

Nerve, Ulnar, Compression Neuropathy of the, A Com-
mon Condition Occurring at Bed Rest, M. N. Estridge

and Roger A. Smith (Or.) 71

Neuropathic Disease, Arthrodesis of a Knee for, Frank

E. Winter (CR) 33

Neuropathy, see Compression Neuropathy of the Ulnar
Nerve

Newer Concepts in Relation to Hypertension, Louis N.

Katz (Or.) 201

Newer Penicillins, The, Harold J. Simon (Or.) 135

Newly Appointed Deans (CMA) 182

Next Step, The (King-Anderson, Care for Aged) (Ed.) 84

Nonpolioviruses and Paralytic Disease, Robert L. Ma-
goffin and Edwin H. Lennette (Or.) 1

Nursing Homes and Related Facilities, Accreditation

of, Charles E. Schoff (Or.) 298

Nursing, Objectives and Program of the A.M.A. Com-
mittee on (I) 326

Objectives and Program of the A.M.A. Committee on

Nursing (I) 326

Occlusive Disease, Management of Peripheral Arterial,

Travis Winsor (Or.) 152

Occupational Health, see Committee on

Operating Table, Mechanical Aids at the, Richard C.

Thompson and William B. Neff (Or.) 28

Operations on the Inguinal Area of Young Children,

Surprises in, Richard M. Marks (Or.) 75

(Osteopaths) Time for LTnification (Ed.) 36

Papillary Carcinoma of the Renal Pelvis Following
Cystectomy and Bricker Procedure for Carcinoma of

the Bladder, Jerry B. Miller and Joseph J. Kaufman

(CR) 355

Paralytic Disease and Nonpolioviruses, Robert L. Ma-
goffin and Edwin H. Lennette (Or.) 1

Parathion Poisoning — A New Antidote!, see Commit-
tee on Occupational Health

Penicillins, The Newer, Harold J. Simon (Or.) 135

Pesticides (Parathion Poisoning), see Committee on
Occupational Health

Physical Examinations, Pre-Placement, see Committee
on Occupational Health

Physician in Civil Defense, A Role for the, Max L.
Lichter (Or.) 24

Physicians in California, Characteristics of, see Bureau
of Research and Planning

Physicians, Type of Practice, see Bureau of Research
and Planning

Piperazine-Senna Preparation, Use of a, Single-Dose
Treatment of Enterobiasis, John T. Ragan (Or.) 338

Poisoning, Parathion, A New Antidote!, see Committee
on Occupational Health

Pollen, see Hay Fever

VOL. 97, NO. 6

DECEMBER 1962

397

Post-Tuberculous Bronchiectasis — Indications for Surgi-
cal Treatment, Neal C. Hamel, John N. Briggs and

Thomas A. Schulkins (Or.) 233

Practice of Physicians, Type of, see Bureau of Research
and Planning

Pregnancy and Appendicitis, Ruth M. King and Gail

V. Anderson (Or.) 158

Prenatal Care — A Group Psychotherapeutic Approach,

Ronald Joseph Pion, Joshua S. Golden and Alexan-
der B. Caldwell, Jr. (Or.) 281

Primary Adenocarcinoma of the Appendix — A Report
of Two Cases, Paul Michael, Clyn Smith, Jr., Carl

Dubuy and John Anderson (CR) 174

Pripsen Granules, see Piperazine-Senna

Proposed Constitutional and Bylaw Amendments

(CMA) 109-120, 373-375

Protein Profiles, Serum, in Coccidioidomycosis, William
B. Reed, Charles L. Heiskell, Charles W. Holeman

and Charles Carpenter (Or.) 333

Psychiatric Aspects of Psychomotor Epilepsy, A. E.

Bennett (Or.) 346

Pulmonary Operations in Emphysematous Patients,

Ivan A. May (Or.) 350

Radiation Exposure, Acute, Committee on Occupational

Health (CMA) 193

Radiation, Hazards of, Edward Teller (Or.) 257

Radiation Nephritis, Acute, John N. Baldwin and Jack

W. C. Hagstrom (CR) 359

Recurrent Tetanus, Harvey D. Cain and Frank G. Falco

(CR) 31

Rehabilitation, Geriatric, The Challenge and the Goal,
David Rubin (Or.) 170

Relative Value Studies, see Bureau of Research and
Planning

Renal Failure, Acute, see Rupture of Abdominal Aortic
Aneurysms, etc.

Renal Pelvis, see Papillary Carcinoma of the Bladder
Renal Transplantation, Human, see Homotransplanta-
tion of the Kidney

Repair of Vesico-Vaginal Fistula, Edward C. Hill (Or.) 216

Research and Planning, see Bureau of

(Retirement Plan — Tax Deductibility) The Keogh Bill

(Ed.) 366

Retroperitoneal Free Air, Lawrence Duckler (CR) 35

Role for the Physician in Civil Defense, A, Max L.

Lichter (Or.) 24

Rupture of Abdominal Aortic Aneurysms Complicated
by Acute Renal Failure and Aspergillosis, H. Vernon
Freidell and William F. Gebhart (CR) 80

“Second Aid,” see Committee on Occupational Health
Senior Citizens, Health Insurance for, see Bureau of Re-
search and Planning

Serum Protein Profiles in Coccidioidomycosis, William
B. Reed, Charles L. Heiskell, Charles W. Holeman

and Charles Carpenter (Or.) 333

Single-Dose Treatment of Enterobiasis — Use of a New
Piperazine-Senna Preparation, John T. Ragan (Or.) 338
Skin Closure — A Disposable Atraumatic Instrument for
Office Procedures, Marthe E. Brown and Adolph M.

Brown (Or.) 291

Snakebite, Use of the Artificial Kidney in, Donald B.

Frazier and Frank H. Carter (CR) 177

Spastic Dysphonia, Further Study on, Bernard A.

Landes (Or.) 77

Spreading of Warts by Metal Expansion Watch Bands,

The — A Report of Three Cases, Clete Dorsey (CR) .. 176

Standards of Therapy for Tuberculosis, 1962, W. H.

Oat way, Jr., and David Salkin (Or.) 142

Subclinical Hypothyroidism — Recognition and Treat-
ment, Paul Starr (Or.) 263

Supervoltage X-Ray, see Cancer Therapy (by)

Surprises in Operations on the Inguinal Area of Young
Children, Richard M. Marks (Or.) 75

Tetanus, Recurrent, Harvey D. Cain and Frank G.

Falco (CR) : 31

Three New Deans of Medical Schools in California
(David B. Hinshaw, Loma Linda University, Sherman
M. Mellinkoff, UCLA School of Medicine and Ben-
jamin B. Wells, California College of Medicine)

(CMA) 182

Time for Unification (Ed.) 36

Toenail Problems, “Ingrown” and Other, Surgical

Treatment (of) , Marshall W. Johnstone (Or.) 222

Transactions of House of Delegates (CMA) 86

Transfusions — Hazardous Acid-Base Changes with Ci-
trated Blood, Jovita M. San Pedro, Seizo Iwai, Mit-

suo Hattori and M. Digby Leigh (Or.) 16

Transplantation, Renal, see Homotransplantation of the
Kidney

Tuberculosis, Pulmonary, Bronchial Division in the

Treatment of, John D. Steele (Or.) 64

Tuberculosis, Standards of Therapy, 1962, W. H. Oat-
way, Jr., and David Salkin (Or.) 142

Tumor, Brain, see Dental Infection
Type of Practice of Physicians in Non-Federal Prac-
tice in California for Three Periods: Mid-1959 to
January, 1962, and Other Comparative Data, see
Bureau of Research and Planning

Ulnar Nerve, Compression Neuropathy of the, A Com-
mon Condition Occurring at Bed Rest, M. N. Estridge

and Roger A. Smith (Or.) 71

Umbilical Cord in the Newborn, Care of, A Program to
Reduce Infection and Promote Healing, John B. Sar-
racino, Patricia A. Ryan and Ellen Mastroianni (Or.) 22

Unification, Time for (Ed.) 36

Use of the Artificial Kidney in Snakebite, Donald B.
Frazier and Frank H. Carter (CR) 177

Vesico-Vaginal Fistula, Repair of, Edward C. Hill (Or.) 216

Viral Hepatitis — A Study of Hyperbilirubinemia with
Acholuria in Convalescence, Allan G. Redeker and

Arthur Kahn (Or.) 341

Warts, Spreading of, by Metal Expansion Watch Bands,

A Report of Three Cases, Clete Dorsey (CR) 176

Welcome Forty First (Ed.) 179

Wells, Benjamin B., Dean, California College of Medi-
cine, Newly Appointed (CMA) 182

What Scope Health Insurance?, Edwin F. Daily (Or.) 58

Workmen’s Compensation in California, Frederick A.

Fender (Or.) 227

Worry and Anxiety as Aspects of Normal Behavior,
Judd Marmor (Or.) 212

X-Ray, Supervoltage, see Cancer Therapy — Evaluation

“YES” on 22 (Ed.) 179

398

CALIFORNIA MEDICINE

EDITORIALS

Chloramphenicol, Ralph 0. Wallerstein 180

Communications 303

Keogh Bill (Tax Deductibility of Retirement Plans).... 366

Medical Assistance to the Aged 237

Medical Education Loans 238

Next Step, The (King-Anderson Bill — Care for Aged) 84

Time for Unification (Osteopaths) 36

Welcome Forty First (Osteopaths) 179

“YES” on 22 (Osteopaths) 179

CALIFORNIA MEDICAL
ASSOCIATION

Council Meeting Minutes:

481st Meeting, May 19, 1962 38

482nd Meeting, July 7, 1962 184

483rd Meeting, Aug. 25, 1962 239

484th Meeting, September 29, 1962 305

485th Meeting, November 3, 1962 368

Committee on Occupational Health:

10. The Industrial “Blank Check” 122

11. Acute Radiation Exposure 190

12. Parathion Poisoning — A New Antidote 245

13. “Second Aid” 312

14. Pre-Placement Physical Examinations — Asset or

Liability 377

House of Delegates, C.M.A., Transactions 86

Newly Appointed Deans 182

Principles of a Sound Program for Medical Care (Re-
port of Ad Hoc Committee) 372

Proposed Constitutional and Bylaw
Amendments 109-120, 373-375

INFORMATION

Bureau of Research and Planning:

Hospital Bills — What Proportion Is Paid by Insur-
ance? 45

Inability of the Consumer Price Index to Measure

“Cost of Quality” of Medical Care 128

Type of Practice of Physicians in Non-Federal Prac-
tice in California for Three Periods (from) Mid-

1959 to January, 1962 : 195

Financing and Provision of Medical Care in Cali-
fornia 249

Use of, and Satisfaction with, C.M.A. Relative Value
Studies by Physicians in Active Practice in Cali-
fornia 323

Characteristics of Physicians in California, Spring,

1961 317

Health Insurance for Senior Citizens 381

Objectives and Program of the A.M.A. Committee on
Nursing 326

BOOK REVIEWS

Acquired Surgical Lesions of the Esophagus, Storey 255

Activities of Medical Consultants, Vol. 1, Internal Med-
icine in World War II, Medical Department , U. S.

A rmy 49

D E

Abdun-Nur, Assed Simon, Tarzana, June 16, 1962 41

Almada, Albert Alvin, Auburn, Oct. 9, 1962 379

Anderson, James F., Los Angeles, May 27, 1962 41

Barnard, Harold Dewey, Las Vegas, May 7, 1962 41

Beers, Reid L., Glendale, Oct. 9, 1962 379

Bloomfield, Arthur L., San Francisco, July 5, 1962. .126, 191
Bogen, Emil, Arcadia, Sept. 19, 1962 310

Atlas of Head and Neck Surgery, Lore, Jr 49

Ciba Foundation Study Group No. 11 — Mechanism of
Action of Water-Soluble Vitamins, De Reuck and

O’Connor 199

Ciba Foundation Symposium on Renal Biopsy, IF olsten-

holrne and Cameron 256

Ciba Symposium on Shock — see Shock

Clinical Obstetrics and Gynecology — March 1962 — Vol.

5, No. 1, Newton and Scott 256

Drug Therapy, Ferguson 200

Electrocardiography — 3rd Ed., Dimond et al 255

Essentials of Pediatric Psychiatry, Meyer et al 393

Financing Medical Care, Schoeck 200

Fundamental Skills in Surgery, Neal on 391

Illustrated Manual of Neurologic Diagnosis, Collins 391

Internal Medicine in World War II, Medical Depart-
ment, United States Army 49

Introduction to the Study of Disease — 5th Ed., Boyd 332

Manual of Electrotherapy, A — 2nd Ed., IF atkins 199

Martini’s Principles and Practice of Physical Diagnosis

— 3rd Ed., Kneeland and Loeb 254

Mechanism of Action of Water-Soluble Vitamins — Ciba
Foundation Study Group No. 11, De Reuck and

O’Connor 199

Medical Department, United States Army, Internal
Medicine in World War II, Vol. I, Activities of Med-
ical Consultants, Office of the Surgeon General, De-
partment of the Army 49

Medical Pharmacology, Goth 254

Modern Medical Treatment, Miller 390

Mold of Murder, The, Bromberg 392

Nature of Psychotherapy, The, Bromberg 389

Postpartum Psychiatric Problems, Hamilton 50

Postthrombophlebitic Syndrome, The, Popkin 332

Practical Anesthesiology, Artusio-Mazzia 390

Problems of Blood Pressure in Childhood, Moss and

Adams 332

Progress in Medicinal Chemistry — Vol. I, Ellis and

West 200

Progress in Radiation Therapy, Vol. II, Buschke 392

Properties of Membranes and Diseases of the Nervous

System, Tower et al 390

Radioactive Isotopes in Medicine and Biology: Medi-
cine— 2nd Ed., Silver 50

Reluctant Surgeon, Kobler 386

Renal Biopsy, Ciba Foundation Symposium on, W ol-

stenholme and Cameron 256

Self-Hypnosis, Sparks 199

Shock — Pathogenesis and Therapy, Ciba 255

Strabismus, Berke et al 389

Suicide and Mass Suicide, Meerloo 199

Textbook of Obstetrics, Reid 388

Textbook of Ophthalmology, 7th Ed., Adler 392

Vector Electrocardiography, Uhley 49

T H S

Booke, S. Gerald, Monrovia, June 28, 1962 126

Boyd, Walter H., Long Beach, Oct. 22, 1962 379

Boyer, William Francis, Indio, June 7, 1962 41

Brickley, Paul M., Santa Barbara, Jan. 11, 1962 41

Brosemer, Lowell R., Sacramento, June 26, 1962 126

Brown, Walter H., Palo Alto, August 6, 1962 190

Butler, Fonzie William, Los Angeles, July 18, 1962 190

VOL. 97, NO. 6 • DECEMBER 1962

399

Byma, Garrett Ralph, San Bernardino, Oct. 10, 1962.... 379

Caldwell, George Woodrop, Azusa, Sept. 6, 1962 247

Campbell, Walter Mac., Sacramento, June 15, 1962 126

Canney, Philip C., San Rafael, July 12, 1962 190

Christopoulos, Basilios K., Oakland, Aug. 12, 1962 247

Cilley, Herbert Arthur, San Jose, May 24, 1962 41

Cornel], Harold Davis, Chula Vista, Sept. 7, 1962 247

Dickinson, Charles Chester, Chico, May 24, 1962 41

Ehrenclou, Olive Nisley, San Francisco, March 23, 1962 247
Faulkner, James Lawrence, Red Bluff, Oct. 24, 1962.... 379

Fogel, Edward Theodore, Los Angeles, May 14, 1962 41

Fowler, George W. J., Los Gatos, Oct. 17, 1962 379

Ghrist, Orrie E., Glendale, August 5, 1962 190

Goorwitch, Joseph, Los Angeles, Oct. 1, 1962 310

Gordon, George 0., Long Beach, July 18, 1962 190

Gould, Arthur Abraham, Norwalk, July 25, 1962 190

Gowan, Charles H., Glendale, Oct. 15, 1962 379

Gray, George Alexander, San Jose, June 6, 1962 41

Green, George B., Burlingame, Feb. 6, 1962 41

Hagen, Horace, Pebble Beach, April 26, 1962 41

Hansen, Arild Edsten, Oakland, Oct. 16, 1962 379

Hansen, Oluf Steffen, Los Angeles, Oct. 30, 1962 379

Hauser, Vernon F., Pasadena, Oct. 20, 1962 379

Hebert, Arthur Winfred, Lodi, July 30, 1962 190

Hedge, Arden Russell, Monrovia, Aug. 15, 1962 247

Hillyer, LeRoy, Los Banos, Oct. 3, 1962 310

Howard, Burt Foster, Sacramento, Aug. 20, 1962 247

Huff, Lucius Johnson, Berkeley, February 9, 1962 126

Irvine, Robert Steele, San Carlos, Aug. 14, 1962 247

Jackson, John Ernest, Los Angeles, July 30, 1962 190

Jamentz, Samuel K., Pasadena, Sept. 15, 1962 310

Jensen, Frederick Grover, Long Beach, Oct. 25, 1962 ... 379

Johnson, Donald W., Needles, July 22, 1962 190

Johnson, Harold Stephen, Long Beach, Sept. 22, 1962.... 310

Johnson, Weston P., Inglewood, July 23, 1962 190

Jones, James Earl (J. Earl), Barstow, July 28, 1962 379

Jones, Newell, Encino, June 18, 1962 126

Kern, Louis R., Los Angeles, Oct. 5, 1962 310

Kohn, Frank, Tulare, June 18, 1962 126

Kinslow, Frank Aloysius, San Francisco, Oct. 29, 1962.. 379

Kuh, Clifford, Oakland, Sept. 15, 1962 310

Lacey, John Mark (J. Mark), La Crescenta, May 15,

1962 41

Larson, Ernest Eric (E. Eric), Laguna Beach, Oct. 22,

1962 379

Leachman, Ream S., Vallejo, July 7, 1962 190

Leo, Robert J., Visalia, May 30, 1962 41

Levisohn, Max, Fresno, Aug. 23, 1962 247

Lewis, Harvey Alvin, Beverly Hills, July 21, 1962 190

Lorch, Alvin H., San Diego, July 23, 1962 190

Luke, Ian W., San Mateo, May 29, 1962 41

Mahlmann, Carl, Riverside, Died in 1962 190

Majors, Ergo Alexander, Bass Lake, Oct. 20, 1962 379

Marsden, Samuel Arthur, Santa Ana, November 22,

1961 190

Mattera, Vincent J., San Diego, June 3, 1962 41

Messenger, Thomas T., Avenal, May 24, 1962 42

Moore, Chester Biven, Belvedere, May 3, 1962 42

Morgan, John A., Modesto, Sept. 30, 1962 310

Morris, John Knox Jr., Modesto, Sept. 16, 1962 310

Morrison, Norman Donald, San Mateo, May 27, 1962 42

Muller, Harold P., Berkeley, May 17, 1962 42

Newman, Harold, Chico, Aug. 20, 1962 247

Nisbet, Thomas W., Corona Del Mar, July 17, 1962 190

O’Grady, William Edward, San Francisco, Oct. 27, 1962 379

Ostrander, Harold R., Covina, Aug. 28, 1962 247

Peters, Lindsay, Santa Barbara, Aug. 3, 1962 247

Pyle, Wynand, Pasadena, Oct. 2, 1962 310

Quirin, Lloyd F., San Francisco, Oct. 14, 1962 379

Reeves, Edwin Wiley, Salinas, June 10, 1962 42

Ress, Irving Leroy, Beverly Hills, Sept. 16, 1962 310

Rose, S. Paul, San Mateo, Died in 1962 42

Rush, Richard Cox, San Fernando, May 8, 1962 42

Schiff, Hans, Los Angeles, Aug. 10, 1962 247

Schwarz, Alfred Joseph, San Anselmo, Sept. 9, 1962 247

Simmonds, Raymond J., Sacramento, May 7, 1962 42

Smith, Willard Leroy, Covina, Sept. 29, 1962 380

Smylie, Robert S., San Diego, July 16, 1962 380

Stabel, John Alois, Sacramento, June 14, 1962 126

Swinney, Raymond Woolridge, Long Beach, Aug. 8,

1962 247

Tasher, Dean Charles, San Bernardino, May 21, 1962 42

Thom, Wenonah King, Chico, Sept. 27, 1962 310

Tirrell, C. Malcolm (Chester), Redlands, June 5, 1962 42

Tobias, Siegfried Fritz, Grass Valley, June 29, 1962 190

Townsend, Guy Walter, Los Angeles, Sept. 26, 1962 310

Turley, John G., Los Angeles, Sept. 13, 1962 310

Walthall, Felix Edward, Poway, May 3, 1962 42

Wedell, William John, San Francisco, May 19, 1962 42

Weinberg, Sydney L., Los Angeles, Aug. 17, 1962 247

Westphal, Glenn Albert, Elsinore, July 10, 1962 190

Wood, Avery Edwin, Watsonville, Aug. 14, 1962 247

Wood, Walter W„ Upland, Sept. 19, 1962 380

Wynns, Harlin LeRoy, San Carlos, Sept. 12, 1962 310

Zumwalt, Fred H., San Francisco, Sept. 16, 1962 310

* I

400

CALIFORNIA MEDICINE

....the first choice of many physicians
to relieve aches, pains, fever, and
general malaise of colds and flu.

Symptomatic and supportive treatment of patients with upper respiratory infections still
consists largely of rest, analgesics, fluids and nasal decongestants. During the fateful
influenza epidemic of 1918, ‘Empirin’ Compound was widely used and became well
known as a well tolerated and reliable analgesic combination. It was one of the few avail-
able analgesic products effective in simultaneously reducing fever and relieving the general
malaise which often accompany the flu.

Later, ‘Empirin’ Compound with Codeine took its place with the widely used ‘Empirin’
Compound, as a product useful when increased analgesia or antitussive action was desired.
Today, ‘Empirin’ Compound with Codeine is one of the most widely prescribed drugs in
medicine, providing physicians with a dependable analgesic, especially useful in relieving
the symptoms of colds and flu. We believe you will also find ‘Empirin’ Compound with
Codeine Phosphate gr. XA (16 mg.) or gr. V2 (32 mg.) particularly useful in treating the
troublesome cough that is often part of the influenza symptom complex.

‘EMPIRIN’ COMPOUND with CODEINE PHOSPHATE *

gr. Vb

gr. 'A

gr. Vz

gr- 1

IOO

TABLOID * T

‘Empirin'

Compound

Codeine Phosphate, No. I

■TABLOID' -* i.

“‘Empirin - ‘
Compound

Codeine Phosphate, No. 2

■TABLOID S 111

“‘Empirin’^

Compound

Codeine I’liO'phatc, No. 4

■TABLOID' \ p

-‘Empirin’-'

Compound

Codeine Phosphate. No. 3

* Available on oral prescription where State law permits. Subject to Federal Narcotic Regulations.

fe BURROUGHS WELLCOME & CO. (U.S.A.) INC., Tuckahoe, N.Y.

Effective

WEIGHT

CONTROL

When it’s important to control weight
you can strengthen your patient’s will
power by prescribing Fetamin® as an
adjunct to your favorite dietary regimen.

Fetamin® provides Methamphetamine,
a more powerful appetite depressant;
Pentobarbital, to avoid nervous side effects*
and a complete dietary supplement of all
the minerals and vitamins essential to
proper nutrition.

The small, odorless, tasteless tablets
ensure patient cooperation.

CONTRAINDICATIONS: Cardiovascular

disease, especially when associated with
hypertension.

SIDE EFFECTS: No effects on blood, urine,
renal or hepatic functions have been noted.
Minimal side effects have been observed
occasionally: dry mouth, insomnia, nausea,
palpitations, and nervousness.

DOSAGE: One tablet taken one-half to one
hour before each meal. May be habit forming.
SUPPLIED: Bottles of 100, 500 and 1,000

EACH TABLET CONTAINS:

d-Methamphetamine HC1 5.0 mg

Pentobarbital Sodium 20.0 mg

Vitamin A Acetate 2500 USP units

Vitamin D2 250 USP units

Ascorbic Acid (Vitamin C) .... 10.0 mg

Thiamine Mononitrate

(Vitamin B,) 2.0 mg

Riboflavin (Vitamin B2) 2.0 mg

Niacinamide (Vitamin B3) 5.0 mg

d-Calcium Pantothenate

(Vitamin B5) 1.0 mg

Pyridoxine HC1 (Vitamin Bc).. 1.0 mg

Ferrous Gluconate 65.0 mg

(Iron 7.5 mg)

Calcium Lactate 270.0 mg

(Calcium 35.0 mg)

Copper (as Sulfate) 0.15 mg

Manganese (as Citrate soluble) .. 0.25 mg

Zinc (as Oxide) 0.08 mg

Potassium (as Chloride) 5.0 mg

Magnesium (as Carbonate) 2.5 mg

COMPLETE LITERATURE AND SAMPLES ON REQUEST.

Mission

Pharmacal Co.

SAN ANTONIO 6, TEXAS

Use of False Vocal Cords
Can Cause Hoarseness

Speaking with the false vocal cords is a common
cause of hoarseness, according to Dr. Herbert L.
Fred, Baylor University College of Medicine,
Houston.

The vocal cords, two small bands of tissue, are
made up of the false cords and the true cords,
which are normally used for speaking. The false
cords lie above the true cords in the larynx, or
voice box.

Using the false cords for speaking makes the
voice much lower than normal with a small range
of pitch, Dr. Fred wrote in the October Archives of
Internal Medicine, published by the American Med-
ical Association.

In typical cases, hoarseness varies in severity and
often is worse at the end of the day, he said. Inter-
mittent loss of voice, voice-cracking, a feeling of
tiredness in the throat, fear of speaking, and per-
sistent attempts to clear the throat are other fre-
quent symptoms, he said.

The possible causes of the condition include psy-
chological stress, abuse of the voice, and disease
of the larynx, Dr. Fred said, but in many cases
the cause cannot be found.

Speech therapy is useful and helps some patients
to regain and maintain normal speech, he said, but
others do not respond to any form of treatment.

RALEIGH HILLS
HOSPITAL*

Member of the American Hospital Association
Recognized by the American Medical Association

EXCLUSIVELY for the TREATMENT of

ALCOHOL ADDICTION

by Conditioned Reflex and Adjuvant Methods

MEDICAL STAFF:

John R. Montague, M.D. Merle M. Kurti, M.D.
Norris H. Perkins, M.D.

John W. Evans, M.D., Consulting Psychiatrist

ADMINISTRATORS:

Larrae A. Haydon Jean B. Tanner

RALEIGH HILLS HOSPITAL

6050 S.W. Old Schools Ferry Road
Portland 7, Oregon
Mailing Address: P. O. Box 366
Telephone: CYpress 2-2641

*FORMERLY RALEIGH HILLS SANITARIUM, INC.

CALIFORNIA MEDICINE

he 1, 1960, Orinase was
tinued. For six weeks,
was on insulin (15, then
I finally 25 units daily).

In mid-July, the patient was
returned abruptly to Orinase
therapy, this time at a dosage
of 2.5 gm. (5 tablets) daily.
With a diet and Orinase,
satisfactory control was re-
established. Since that
time, 2.5 gm. of Orinase has
been the routine dosage.

Mr. T. continues in his pattern of
constant travel and irregular
hours. His diabetes is well
controlled on a diet and Orinase,
and he has no special difficulty
in carrying out his work schedule.

njj g oral agents for the treatment of diabetes, Orinase*
ill itamide) stands in a unique position. It alone has had
e ears or more of day-to-day routine clinical use in the
ir s of thousands of physicians throughout the country.
;(i rdingly, there are by now a considerable number of
Jl long-term Orinase-treated patients. This series of
'i .se five-year case histories has been prepared to illus-
it and exemplify some aspects of actual experience in
ai igement. Patient data made available to us by physi-

cians have been factually incorporated; however, patients’
identities have been concealed. Any inquiries regarding
this case history series should be addressed to: Medical
Department, The Upjohn Company, Kalamazoo, Michigan.

Orinase is supplied in bottles of 50 and 200 tablets.
Each tablet contains: Tolbutamide ... 0.5 gm.

Reminder advertisement. Please see package insert
for detailed product information.

Upjohn

The Upjohn Company, Kalamazoo, Michigan

A.M.A. Broaches Plan to Boost Pay
For Interns, Residents

Income from prepaid medical plans should be
made available to interns and residents when they
perform services for which fees are provided under
such plans, an American Medical Association re-
port said recently.

“Many hospitals formerly accepting predomi-
nantly indigent patients now find their patients
capable of paying for all or a portion of their care
either directly or through some third party,” the
report said. “These ‘paying patients’ include not
only those covered by some form of insurance, but
also those covered by welfare department fees for
professional services.”

This changed economic status of the hospital
patient population offers a possible solution to the
“inappropriately low” financial compensation of in-
terns and residents, it said.

The special report, prepared by the A.M.A. Coun-
cil on Medical Education and Hospitals and the
A.M.A. Council on Medical Service, will be con-
sidered by the House of Delegates, policy-making
body of the A.M.A., at the A.M.A. clinical meeting
at Los Angeles, November 25-28. It was published
in the October 27 Journal of the American Medical
Association.

Since patients capable of paying for medical serv-
ices necessarily are now becoming of increasing

importance to the training of interns and residents,
this results inevitably in interns and residents pro-
viding medical services for which professional fees
are available, the councils said. Fees attributable
to services provided by interns and residents to pay-
ing patients should be collected and used exclusively
for financial support of hospital training programs
for graduate medical students, it said.

All applicable fees should be collected and de-
posited in a special fund, according to the report.
Such funds have been established in some hospitals,
a recent survey showed.

As to the level of compensation, the councils said
the intern and resident “should receive a salary
which will enable him to support himself and his
family without the necessity of resorting to outside
help or work.”

“A specific minimum salary cannot te set in view
of geographic and other differences between hos-
pitals, but cost-of-living studies might be used as
guides in the development of appropriate salaries,”
the report said.

The councils also urged “an objective reappraisal
of the true value of house officer service.”

Citing the fact that 85 per cent of medical gradu-
ates spend 1 to 4 years in residency training and
most of these face 2 to 5 years of deficit financing
before entering practice, the councils said reform

(Continued on Page 78)

ENDOCRINOLOGY IN GENERAL PRACTICE

THE HOUSE OF ETHICAL
PHARMACEUTICALS

We would like to take this opportunity
of inviting you to attend one of our highly
informative classes dealing with Endocrin-
ology in General Practice.

LANPAR COMPANY • • • 2727 W. MOCKINGBIRD LANE • • • DALLAS 35, TEXAS

CALIFORNIA MEDICINE

PEAK EFFICIENCY
WHEN YOU NEED IT

Potassium Penicillin
V, Abbott.

250 mg.

(400,000 units)

Caution: Federal law
prohibits dispensing
without prescription.

I ABBOTT ■

Single Oral Doses to Fasting Subjects*

. . . where your primary concern is high peak
serum concentrations, you can prescribe Com-
pocillin-VK at full therapeutic dosage and get the
maximum antibacterial activity possible with
an oral penicillin. The chart above shows the
rapid peak blood levels obtained with 400,000
units (250 mg.) of Compocillin-VK. Actually,
these peaks occur faster — and are higher — than
those obtained with intramuscular penicillin G.
Indeed, Compocillin-VK has been used in cases
previously reserved for parenteral treatment.
The safety advantage (oral vs. injectable) goes
without saying.

"Chart data from two separate studies completed by the Micro-
biologic and Medical Departments of Abbott Laboratories.

ABBOTT LABORATORIES NORTH CHICAGO, ILLINOIS

2X0274

A.M.A. Broaches Plan to Boost Pay
For Interns, Residents

(Continued from Page 70)

of the traditional level and method of financial com-
pensation of house officers is vital to attract an
adequate number of young persons into the medical
profession and to assure that all future physicians
receive the full degreee of training they desire.

The increasing cost of hospitalization to the
patient is a major concern of the public, the pro-
fession and hospitals, the report pointed out,
adding:

“Under the present system of financing intern
and resident programs, an increased burden will
be placed on the patient as hospitals generally in-
crease the salaries paid to house officers.”

The community, particularly its medical com-
ponent, have an opportunity and responsibility to
influence those concerned with the operation of
prepaid medical care plans to assure that such in-
come be made available for graduate training pro-
grams, the councils said. The methods for improving
the salary level must be developed locally through
the mutual efforts of hospitals, health insurance
groups and welfare and other community agencies,
they said.

If contributions from the hospital governing
body, and from the community, as well as collec-
tions of fees for the care of paying patients are
insufficient to provide the desired salary levels, then

the hospital’s attending staff should accept the re-
sponsibility for providing the needed funds by the
most appropriate means, they said.

In developing an appropriate method, the councils
said, any increased costs involved should be spread
among the hospital, attending staff, and patients in
proportion to the benefits each receives from the
services of the interns and residents.

Recognizing that there are difficulties regarding
the billing and collecting of fees from paying
patients or prepayment plans for the services of
interns and residents, the councils said these dif-
ficulties might be obviated if the interns and resi-
dents were employed by a partnership of the
hospital’s attending staff. Under such an arrange-
ment, they said, the partnership could bill and
collect fees ethically and legally for the services of
its employees.

Field Test of Simple, Foam-Producing Chemical Contra*
ceptive — A. Russell and A. R. Parchment. New York J,
Med., 62:2491 (Aug. 1) 1962.

A field trial of contraceptive foam-producing liquid used
with an insertable moistened sponge was carried out in
Jamaica, West Indies. The study, which lasted an average
period of nine months, included 640 women. There were 18
pregnancies, or 4.2 per 100 years of woman exposure, as
compared with the normal rate in the population of 70 to 80
per 100 exposure years. The method is inexpensive, simple,
and suited for use by women with little education and low
income.

Guest ranch living

in this friendly Valley of the Sun resort area lends

a vacation-like atmosphere to the patient’s stay at
Camelback Hospital. Peaceful Camelback Mountain,
standing serenely above the surrounding citrus grove,
helps provide a setting to exercise a natural
therapeutic effect on patients as they enjoy the
well-rounded recreational program.

Approved by the Joint Commission on
Accreditation of Hospitals ; and
The American Psychiatric Association

5055 North 34th Street
AMherst 4-4111
PHOENIX, ARIZONA
0TT0 L. BENDHEIM, M.D, F.A.P.A, Medical Director

CALIFORNIA MEDICINE

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